Provider Demographics
NPI:1548435183
Name:JOHNSON, JESSICA S (MNT)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-3320
Mailing Address - Country:US
Mailing Address - Phone:352-540-6800
Mailing Address - Fax:352-754-4132
Practice Address - Street 1:300 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3320
Practice Address - Country:US
Practice Address - Phone:352-540-6800
Practice Address - Fax:352-754-4132
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL898669133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL898669OtherCRD
IL898669OtherCRD