Provider Demographics
NPI:1043615560
Name:JOHNSON, JENNIFER DIANE (FNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:DIANE
Other - Last Name:PSOTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:27431 N. LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185
Mailing Address - Country:US
Mailing Address - Phone:608-358-8449
Mailing Address - Fax:
Practice Address - Street 1:725 AMERICAN AVENUE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188
Practice Address - Country:US
Practice Address - Phone:212-928-8800
Practice Address - Fax:262-928-0648
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI171464-30163W00000X
WI6088-33363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner