Provider Demographics
NPI:1710310388
Name:JOHNSTON, JACQUELINE JOAN (112561-30)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:JOAN
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:112561-30
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N3977 ROBIN LN
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-9336
Mailing Address - Country:US
Mailing Address - Phone:715-735-9425
Mailing Address - Fax:
Practice Address - Street 1:N3977 ROBIN LN
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-9336
Practice Address - Country:US
Practice Address - Phone:715-735-9425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-18
Last Update Date:2013-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI112561-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse