Provider Demographics
NPI:1366842569
Name:JOHANESON, JESSA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JESSA
Middle Name:
Last Name:JOHANESON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 E BLUE EARTH AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4226
Mailing Address - Country:US
Mailing Address - Phone:507-235-5965
Mailing Address - Fax:
Practice Address - Street 1:1123 E BLUE EARTH AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4226
Practice Address - Country:US
Practice Address - Phone:507-235-5965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121455183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist