Provider Demographics
NPI:1083816383
Name:JOHNSON, JERILYN ANN (PT)
Entity Type:Individual
Prefix:
First Name:JERILYN
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4416 43RD AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-4051
Mailing Address - Country:US
Mailing Address - Phone:612-722-4329
Mailing Address - Fax:
Practice Address - Street 1:1284 CORPORATE CENTER DR
Practice Address - Street 2:SUITE 500
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-1253
Practice Address - Country:US
Practice Address - Phone:651-686-0098
Practice Address - Fax:651-686-0499
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6285225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist