Basic Information
| Provider Information | |||||||||
| NPI: | 1114650033 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 227 EVANS LN | ||||||||
| Address2: | |||||||||
| City: | SPEARFISH | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577831130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6056411750 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1420 N 10TH ST | ||||||||
| Address2: | |||||||||
| City: | SPEARFISH | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577831532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057178595 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2022 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1375 | SD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.