Basic Information
| Provider Information | |||||||||
| NPI: | 1891710984 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | C.N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUZICH | ||||||||
| OtherFirstName: | JACQUELYN | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 811 2ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LITTLE FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563453559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206317000 | ||||||||
| FaxNumber: | 3206320534 | ||||||||
| Practice Location | |||||||||
| Address1: | 811 2ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LITTLE FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563453559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206317000 | ||||||||
| FaxNumber: | 3206320534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 02/16/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R108719-0 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0107328 | 01 | MEDICA | OTHER | 140376C736 | 01 | MN | UCARE MINNESOTA | OTHER | HP33899 | 01 | HEALTH PARTNERS | OTHER | A024 | 01 | MN | TRICARE | OTHER | NA9231028468 | 01 | PREFERRED ONE | OTHER | 044997100 | 05 | MN | MEDICAID | 47G13JO | 01 | MN | BCBS OF MINNESOTA | OTHER |