Provider Demographics
NPI:1568496990
Name:JOHNSON, JERRILYN (PA-C)
Entity Type:Individual
Prefix:
First Name:JERRILYN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JERRILYN
Other - Middle Name:
Other - Last Name:FINLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9146
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:8501 75TH ST
Practice Address - Street 2:SUITE J
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7602
Practice Address - Country:US
Practice Address - Phone:262-898-4400
Practice Address - Fax:262-764-6157
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1069363AM0700X
WI1069-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S68020Medicare UPIN