Provider Demographics
NPI:1942586532
Name:JOHNSON, JENNIER RENEE (PRESIDENT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIER
Middle Name:RENEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PRESIDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 367
Mailing Address - Street 2:8783 2ND STREET S
Mailing Address - City:BROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:55711-0367
Mailing Address - Country:US
Mailing Address - Phone:218-453-5062
Mailing Address - Fax:218-453-5064
Practice Address - Street 1:8783 2ND STREET SOUTH
Practice Address - Street 2:
Practice Address - City:BROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:55711-0367
Practice Address - Country:US
Practice Address - Phone:218-453-5062
Practice Address - Fax:218-453-5064
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN354457310400000X
MNFBL-26096-34148311Z00000X
MN354448311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home