=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639464076
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA L JOHNSON M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2011
-----------------------------------------------------
Last Update Date | 06/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 790 COLLEGE PKWY
-----------------------------------------------------
City | COLCHESTER
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05446-3007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-847-0318
-----------------------------------------------------
Fax | 802-847-6846
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | WRAMC BLDG 2 RM 2G01 6900 GEORGIA AVE NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20307-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 042.0014416
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------