Provider Demographics
NPI:1730630468
Name:JOHNSON, JESSICA MARIS (RN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIS
Other - Last Name:MOATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2129 SW 59TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73119-7024
Mailing Address - Country:US
Mailing Address - Phone:405-713-5873
Mailing Address - Fax:405-713-5816
Practice Address - Street 1:2129 SW 59TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73119-7024
Practice Address - Country:US
Practice Address - Phone:405-713-5873
Practice Address - Fax:405-713-5816
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX862098163WP0808X
OK82477163WP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health