Provider Demographics
NPI:1902112204
Name:JOHNSON, JESSICA RENE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 W THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-2947
Mailing Address - Country:US
Mailing Address - Phone:985-345-1600
Mailing Address - Fax:
Practice Address - Street 1:1910 W THOMAS ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-2947
Practice Address - Country:US
Practice Address - Phone:985-345-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018810183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1895750Medicaid