Basic Information
| Provider Information | |||||||||
| NPI: | 1578008926 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KARISHA | ||||||||
| MiddleName: | JAKOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | KARISHA | ||||||||
| OtherMiddleName: | JAKOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 11538 | ||||||||
| Address2: | |||||||||
| City: | KILLEEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765471538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542459177 | ||||||||
| FaxNumber: | 2542459178 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 S W S YOUNG DR | ||||||||
| Address2: | |||||||||
| City: | KILLEEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765423340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542459175 | ||||||||
| FaxNumber: | 2542137771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2016 | ||||||||
| LastUpdateDate: | 01/26/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP132750 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 366584601 | 05 | TX | MEDICAID |