Provider Demographics
NPI:1215663539
Name:JOHNSON, JESSIE RAE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:RAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:
Other - Last Name:WHEELER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:105 W 8TH AVE STE 7060
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2327
Mailing Address - Country:US
Mailing Address - Phone:217-607-3338
Mailing Address - Fax:
Practice Address - Street 1:101 W 8TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2307
Practice Address - Country:US
Practice Address - Phone:509-474-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL61255987235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist