Healthcare Provider Details

I. General information

NPI: 1811731490
Provider Name (Legal Business Name): JESSILYN MAE JOHANNSEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 STONE PARK BLVD
SIOUX CITY IA
51104-3734
US

IV. Provider business mailing address

4701 46TH ST
SIOUX CITY IA
51108-1548
US

V. Phone/Fax

Practice location:
  • Phone: 712-279-3750
  • Fax:
Mailing address:
  • Phone: 712-560-6686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number126879
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: