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NPI Code Detail

MEDICARE: MRS. JACQUELINE S JOHANSON P.A.-C

MEDICARE: MRS. JACQUELINE S JOHANSON P.A.-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant5601008301MI

General Provider Information

NPI Number : 1952304982
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. JACQUELINE S JOHANSON P.A.-C
Provider Business Mailing Address
First Line : 310 LAFAYETTE AVE SE STE 410
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49503-4693
Country : US
Telephone Number : 616-685-8200
Fax Number : 616-685-8202
Provider Business Practice Location Address
First Line : 310 LAFAYETTE AVE SE STE 410
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49503-4693
Country : US
Telephone Number : 616-685-8200
Fax Number : 616-685-8202
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/23/2005
Last Update Date : 12/28/2021

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Directions to “ MRS. JACQUELINE S JOHANSON P.A.-C” Practice Location

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