Provider Demographics
NPI:1275366197
Name:JOHNSON, JESSICA LYNN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICCA
Other - Middle Name:LYNN
Other - Last Name:MENDENHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:3323 33RD LOOP SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-3921
Mailing Address - Country:US
Mailing Address - Phone:360-556-8326
Mailing Address - Fax:
Practice Address - Street 1:3323 33RD LOOP SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-3921
Practice Address - Country:US
Practice Address - Phone:360-556-8326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61598959363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health