MEDICARE: JESSICA BROOKE JOHNSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	8486	IA

General Provider Information

NPI Number	:	1245487859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA BROOKE JOHNSON DDS

Provider Business Mailing Address
First Line	:	1111 9TH ST STE 190
Second Line	:
City	:	DES MOINES
State	:	IA
Zip	:	50314-2527
Country	:	US
Telephone Number	:	515-244-9136
Fax Number	:	515-244-9153

Provider Business Practice Location Address
First Line	:	1111 9TH ST STE 190
Second Line	:
City	:	DES MOINES
State	:	IA
Zip	:	50314-2527
Country	:	US
Telephone Number	:	515-244-9136
Fax Number	:	515-244-9153

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2008
Last Update Date	:	08/26/2008

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