Provider Demographics
NPI:1215063730
Name:JOHNSON, JESSICA LYNNE (OTR,L)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTR,L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 DE PORRES LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63304-6714
Mailing Address - Country:US
Mailing Address - Phone:314-393-0506
Mailing Address - Fax:
Practice Address - Street 1:12430 TESSON FERRY RD
Practice Address - Street 2:SUITE 352
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2702
Practice Address - Country:US
Practice Address - Phone:866-495-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006030617225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics