Provider Demographics
NPI:1164797072
Name:JOHNSRUD, JACKIE LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:LYNN
Last Name:JOHNSRUD
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 81
Mailing Address - Street 2:
Mailing Address - City:EPPING
Mailing Address - State:ND
Mailing Address - Zip Code:58843-0081
Mailing Address - Country:US
Mailing Address - Phone:701-570-0119
Mailing Address - Fax:
Practice Address - Street 1:306 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-5304
Practice Address - Country:US
Practice Address - Phone:701-580-4912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND865111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor