Provider Demographics
NPI:1952304982
Name:JOHANSON, JACQUELINE S (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:S
Last Name:JOHANSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:S
Other - Last Name:DASCOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:310 LAFAYETTE AVE SE STE 410
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4693
Mailing Address - Country:US
Mailing Address - Phone:616-685-8200
Mailing Address - Fax:616-685-8202
Practice Address - Street 1:310 LAFAYETTE AVE SE STE 410
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4693
Practice Address - Country:US
Practice Address - Phone:616-685-8200
Practice Address - Fax:616-685-8202
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008301363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ42590Medicare UPIN
GA97WCGMKMedicare ID - Type Unspecified