Provider Demographics
NPI:1154949204
Name:JOHNSON, JESSICA PAIGE (CRNA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:PAIGE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GENESYS PKWY STE 2432
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8065
Mailing Address - Country:US
Mailing Address - Phone:810-606-5019
Mailing Address - Fax:
Practice Address - Street 1:1 GENESYS PKWY STE 2432
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8065
Practice Address - Country:US
Practice Address - Phone:810-606-5019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2020-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI135290367500000X
MI4704319822163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse