Provider Demographics
NPI:1386969640
Name:JOHNSON, JESSICA (DO)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 WHITE ST
Mailing Address - Street 2:
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-3327
Mailing Address - Country:US
Mailing Address - Phone:305-204-7178
Mailing Address - Fax:984-203-8463
Practice Address - Street 1:1106 WHITE ST
Practice Address - Street 2:
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-3327
Practice Address - Country:US
Practice Address - Phone:305-204-7178
Practice Address - Fax:984-203-8463
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10946207Q00000X
FLOS13664207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL83-1674568OtherIRS