Provider Demographics
NPI:1780987818
Name:JOHNSON, JENNA (NP)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1459
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-1459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD EAST
Practice Address - Street 2:MAIL ROUTE MN 008-B213
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343
Practice Address - Country:US
Practice Address - Phone:480-490-3507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-11
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011251363L00000X
WANP60908265363LF0000X
NV813759363LF0000X
AZAP11439363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner