Provider Demographics
NPI:1891710984
Name:JOHNSON, JACQUELYN LEE (CNP)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MS
Other - First Name:JACQUELYN
Other - Middle Name:LEE
Other - Last Name:RUZICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:811 2ND ST SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-3559
Mailing Address - Country:US
Mailing Address - Phone:320-631-7000
Mailing Address - Fax:320-632-0534
Practice Address - Street 1:811 2ND ST SE
Practice Address - Street 2:SUITE A
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-3559
Practice Address - Country:US
Practice Address - Phone:320-631-7000
Practice Address - Fax:320-632-0534
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR108719-0363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
0107328OtherMEDICA
MN140376C736OtherUCARE MINNESOTA
HP33899OtherHEALTH PARTNERS
MNA024OtherTRICARE
NA9231028468OtherPREFERRED ONE
MN044997100Medicaid
MN47G13JOOtherBCBS OF MINNESOTA
P37494Medicare UPIN
MN500019836Medicare Oscar/Certification
NA9231028468OtherPREFERRED ONE