Provider Demographics
NPI:1528460003
Name:JOHANNESSEN, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JOHANNESSEN
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:PO BOX 290
Mailing Address - Street 2:
Mailing Address - City:SACKETS HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:13685-0290
Mailing Address - Country:US
Mailing Address - Phone:315-646-3419
Mailing Address - Fax:315-646-1038
Practice Address - Street 1:215 S. BROAD ST.
Practice Address - Street 2:
Practice Address - City:SACKETS HARBOR
Practice Address - State:NY
Practice Address - Zip Code:13685-0290
Practice Address - Country:US
Practice Address - Phone:315-646-3419
Practice Address - Fax:315-646-1038
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY526638-1163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool