Provider Demographics
NPI:1316385271
Name:JOHNSTON, JACQUELYN (PA)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:
Other - Last Name:STORTENBECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:306 N 3RD AVE E
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IA
Mailing Address - Zip Code:50208-3249
Mailing Address - Country:US
Mailing Address - Phone:641-792-4012
Mailing Address - Fax:641-791-0697
Practice Address - Street 1:306 N 3RD AVE E
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:IA
Practice Address - Zip Code:50208-3249
Practice Address - Country:US
Practice Address - Phone:641-792-4012
Practice Address - Fax:641-791-0697
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002403363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant