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General NPI Number Information
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NPI Number | 1104628767
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Entity Type | Individual
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Provider Name | JESSICA L JOHNSON SIMMONS
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Gender | Female
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Dates
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Enumeration Date | 03/25/2025
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Last Update Date | 03/25/2025
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Provider Practice Location Address
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Address Line | 810 E JAMES LEE BLVD
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City | CRESTVIEW
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State | FL
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Zip | 32539-3118
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Country | US
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Telephone | 850-689-5593
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Fax |
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Provider Business Mailing Address
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Address Line | 1771 SHADY CIR
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City | PONCE DE LEON
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State | FL
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Zip | 32455-7031
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Country | US
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Telephone | 850-689-5593
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | DH22470
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License Number State | FL
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