Provider Demographics
NPI:1770472060
Name:JOHNSON, JAKE MICHAEL (PHARMD)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:MICHAEL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 N HIGH POINT RD APT 100
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-2245
Mailing Address - Country:US
Mailing Address - Phone:763-370-0116
Mailing Address - Fax:
Practice Address - Street 1:1821 S STOUGHTON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716-2257
Practice Address - Country:US
Practice Address - Phone:608-260-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-01
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23013-401835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care