Provider Demographics
NPI:1194085969
Name:JOHNSON, JENNIFER LYNN (FNP-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 RIVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HARWOOD
Mailing Address - State:ND
Mailing Address - Zip Code:58042-4020
Mailing Address - Country:US
Mailing Address - Phone:701-412-3170
Mailing Address - Fax:
Practice Address - Street 1:1701 38TH ST S
Practice Address - Street 2:STUITE 101
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4499
Practice Address - Country:US
Practice Address - Phone:701-356-1500
Practice Address - Fax:701-356-1616
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR31754363LF0000X
MNR1890303363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily