Provider Demographics
NPI:1275314619
Name:JOHNSON, JOLENE REBECCA
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:REBECCA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-4248
Mailing Address - Country:US
Mailing Address - Phone:319-444-0184
Mailing Address - Fax:
Practice Address - Street 1:211 N FEDERAL AVE
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-3209
Practice Address - Country:US
Practice Address - Phone:319-444-0184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA132734163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health