Provider Demographics
NPI:1962166801
Name:JOHNSON, JESSICA MARIE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
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 1:826 41ST AVE NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-6650
Mailing Address - Country:US
Mailing Address - Phone:507-273-9829
Mailing Address - Fax:
Practice Address - Street 1:826 41ST AVE NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-6650
Practice Address - Country:US
Practice Address - Phone:507-273-9829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1109178253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency