Provider Demographics
NPI:1750651626
Name:JOHNSON, JACQUELINE E (RN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:E
Last Name:JOHNSON
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 1:2 DEVON RD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-2142
Mailing Address - Country:US
Mailing Address - Phone:631-434-2272
Mailing Address - Fax:631-434-2188
Practice Address - Street 1:2 DEVON RD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-2142
Practice Address - Country:US
Practice Address - Phone:631-434-2272
Practice Address - Fax:631-434-2188
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290100-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse