Provider Demographics
NPI:1629254396
Name:JOHNSON, JENNIFER S (RPH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 SCHOOL CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:LUXEMBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54217-1095
Mailing Address - Country:US
Mailing Address - Phone:920-845-5832
Mailing Address - Fax:920-845-5834
Practice Address - Street 1:125 SCHOOL CREEK TRL
Practice Address - Street 2:
Practice Address - City:LUXEMBURG
Practice Address - State:WI
Practice Address - Zip Code:54217-1095
Practice Address - Country:US
Practice Address - Phone:920-845-5832
Practice Address - Fax:920-845-5834
Is Sole Proprietor?:No
Enumeration Date:2008-01-12
Last Update Date:2008-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13179-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist