MEDICARE: JESSIE JOHNSON RN

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	163W00000X	Registered Nurse	RN-185690	GA
2	163W00000X	Registered Nurse	575835-01	NY

General Provider Information

NPI Number	:	1437996253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSIE JOHNSON RN

Provider Business Mailing Address
First Line	:	1868 TROY AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-2032
Country	:	US
Telephone Number	:	631-747-4288
Fax Number	:

Provider Business Practice Location Address
First Line	:	1868 TROY AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-2032
Country	:	US
Telephone Number	:	631-747-4288
Fax Number	:

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

Provider Enumeration Date	:	07/10/2024
Last Update Date	:	07/10/2024

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