Provider Demographics
NPI:1285340703
Name:JOHNSON, JALISA
Entity type:Individual
Prefix:
First Name:JALISA
Middle Name:
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 1:249 JOHNSONTOWN RD
Mailing Address - Street 2:
Mailing Address - City:LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:39092-9563
Mailing Address - Country:US
Mailing Address - Phone:769-274-1148
Mailing Address - Fax:
Practice Address - Street 1:249 JOHNSONTOWN RD
Practice Address - Street 2:
Practice Address - City:LAKE
Practice Address - State:MS
Practice Address - Zip Code:39092-3909
Practice Address - Country:US
Practice Address - Phone:769-274-1148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health