Provider Demographics
NPI:1588262877
Name:JOHNSON, JESSIE
Entity type:Individual
Prefix:
First Name:JESSIE
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 1:3220 W BRETONS DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-5649
Mailing Address - Country:US
Mailing Address - Phone:719-472-4249
Mailing Address - Fax:
Practice Address - Street 1:550 RIDGEVIEW DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050
Practice Address - Country:US
Practice Address - Phone:719-472-4249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008521225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant