Basic Information
| Provider Information | |||||||||
| NPI: | 1114027737 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSTON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3915 30TH AVE | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531441957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626570222 | ||||||||
| FaxNumber: | 2626577190 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 N MILWAUKEE ST | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531854432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625142700 | ||||||||
| FaxNumber: | 2625143003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2006 | ||||||||
| LastUpdateDate: | 10/31/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10136-024 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 859400066 | 01 | WI | MEDICARE | OTHER |