Provider Demographics
NPI:1528892015
Name:JOHNSTON, JESSICA (EDS)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9575 N STATE ROAD 9
Mailing Address - Street 2:
Mailing Address - City:HOPE
Mailing Address - State:IN
Mailing Address - Zip Code:47246-9760
Mailing Address - Country:US
Mailing Address - Phone:812-546-5001
Mailing Address - Fax:
Practice Address - Street 1:9423 N STATE ROAD 9
Practice Address - Street 2:
Practice Address - City:HOPE
Practice Address - State:IN
Practice Address - Zip Code:47246-9760
Practice Address - Country:US
Practice Address - Phone:812-546-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10247546103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool