Provider Demographics
NPI:1740852235
Name:JOHNSON, JACQUELINE MARIE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 CENTENNIAL RD LOT 96
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0723
Mailing Address - Country:US
Mailing Address - Phone:701-220-9030
Mailing Address - Fax:
Practice Address - Street 1:2500 CENTENNIAL RD LOT 96
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0723
Practice Address - Country:US
Practice Address - Phone:701-220-9030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant