Provider Demographics
NPI:1750648846
Name:JOHANNESSEN, JODI (RN)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:JOHANNESSEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4961 RICE LAKE RD STE 105
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803-8439
Mailing Address - Country:US
Mailing Address - Phone:218-727-0296
Mailing Address - Fax:218-727-4135
Practice Address - Street 1:4961 RICE LAKE RD STE 105
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55803-8439
Practice Address - Country:US
Practice Address - Phone:218-727-0296
Practice Address - Fax:218-727-4135
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR156709-2163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management