Provider Demographics
NPI:1275203549
Name:JOHNSON, JESSICA TYNEA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:TYNEA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 DUNMORELAND ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01109-3261
Mailing Address - Country:US
Mailing Address - Phone:413-219-3689
Mailing Address - Fax:
Practice Address - Street 1:115 DUNMORELAND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01109-3261
Practice Address - Country:US
Practice Address - Phone:413-219-3689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2388726163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice