Provider Demographics
NPI:1750519963
Name:JOHNSON, JENNIFER M (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:
Other - Last Name:RAMBUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:207 W FRONT AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5514
Mailing Address - Country:US
Mailing Address - Phone:701-751-0994
Mailing Address - Fax:701-751-1657
Practice Address - Street 1:207 W FRONT AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5514
Practice Address - Country:US
Practice Address - Phone:701-751-0994
Practice Address - Fax:701-751-1657
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2237225100000X
ND1735225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN721104OtherMEDICARE PTAN