MEDICARE: MS. JESSICA LEIGH JOHNSON

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	103K00000X	Behavior Analyst	834375	NY

General Provider Information

NPI Number	:	1831454578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JESSICA LEIGH JOHNSON

Provider Business Mailing Address
First Line	:	560 HALSTEAD AVE
Second Line	:	APARTMENT 4A
City	:	HARRISON
State	:	NY
Zip	:	10528-3838
Country	:	US
Telephone Number	:	914-497-6424
Fax Number	:

Provider Business Practice Location Address
First Line	:	1890 PALMER AVE STE 404
Second Line	:
City	:	LARCHMONT
State	:	NY
Zip	:	10538-3031
Country	:	US
Telephone Number	:	914-833-1303
Fax Number	:

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

Provider Enumeration Date	:	07/09/2012
Last Update Date	:	07/09/2012

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