Healthcare Provider Details

I. General information

NPI: 1033832878
Provider Name (Legal Business Name): JENNIE JOHNSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11840 S STATE ROUTE 59
PLAINFIELD IL
60585-5652
US

IV. Provider business mailing address

4620 MATHER CT
NAPERVILLE IL
60564-5860
US

V. Phone/Fax

Practice location:
  • Phone: 815-609-2451
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.295215
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: