Provider Demographics
NPI:1811731490
Name:JOHANNSEN, JESSILYN MAE (RN)
Entity type:Individual
Prefix:
First Name:JESSILYN
Middle Name:MAE
Last Name:JOHANNSEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 46TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51108-1548
Mailing Address - Country:US
Mailing Address - Phone:712-560-6686
Mailing Address - Fax:
Practice Address - Street 1:2720 STONE PARK BLVD
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-3734
Practice Address - Country:US
Practice Address - Phone:712-279-3750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA126879163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator