Healthcare Provider Details

I. General information

NPI: 1750648846
Provider Name (Legal Business Name): JODI JOHANNESSEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 04/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4961 RICE LAKE RD STE 105
DULUTH MN
55803-8439
US

IV. Provider business mailing address

4961 RICE LAKE RD STE 105
DULUTH MN
55803-8439
US

V. Phone/Fax

Practice location:
  • Phone: 218-727-0296
  • Fax: 218-727-4135
Mailing address:
  • Phone: 218-727-0296
  • Fax: 218-727-4135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberR156709-2
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: