Healthcare Provider Details

I. General information

NPI: 1124438890
Provider Name (Legal Business Name): JESSICA ELIZABETH JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
MORGANTOWN WV
26506-1200
US

IV. Provider business mailing address

1 MEDICAL CENTER DR
MORGANTOWN WV
26506-1200
US

V. Phone/Fax

Practice location:
  • Phone: 559-882-2738
  • Fax:
Mailing address:
  • Phone: 855-988-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number27084
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: