Provider Demographics
NPI:1366870305
Name:JOHNSON, JESSICA (OPA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 OLD WEISGARBER RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1293
Mailing Address - Country:US
Mailing Address - Phone:865-558-4400
Mailing Address - Fax:
Practice Address - Street 1:1422 OLD WEISGARBER RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-1293
Practice Address - Country:US
Practice Address - Phone:865-558-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-30
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN819246ZX2200X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic Assistant
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ007108Medicaid
TN103I975830Medicare PIN
TNQ007108Medicaid