Provider Demographics
NPI:1811488430
Name:JOHNSON, JACLYN A (RD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 1ST ST S
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-4243
Mailing Address - Country:US
Mailing Address - Phone:320-231-6348
Mailing Address - Fax:320-231-5067
Practice Address - Street 1:1604 1ST ST S
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-4243
Practice Address - Country:US
Practice Address - Phone:320-231-6348
Practice Address - Fax:320-231-5067
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3952133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered