Provider Demographics
NPI:1134884877
Name:JOHNSEN, JORDAN MARIE (RDH)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:MARIE
Last Name:JOHNSEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6307 BERKSHIRE DR # B
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-4658
Mailing Address - Country:US
Mailing Address - Phone:425-770-3652
Mailing Address - Fax:
Practice Address - Street 1:6821 NE 181ST ST STE 102
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:WA
Practice Address - Zip Code:98028-5044
Practice Address - Country:US
Practice Address - Phone:425-486-9211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH009424124Q00000X
WA60768586124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist