Provider Demographics
NPI:1891133740
Name:JOHNSON, JENNIFER L (PHARMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5200 FAIRVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092-8013
Mailing Address - Country:US
Mailing Address - Phone:651-982-7404
Mailing Address - Fax:651-982-7236
Practice Address - Street 1:510 2ND ST SE
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-1706
Practice Address - Country:US
Practice Address - Phone:651-982-7404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120881183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist