Healthcare Provider Details

I. General information

NPI: 1477417053
Provider Name (Legal Business Name): JACQUELINE ANN JOHNSON WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 E SAINT GERMAIN ST STE 100
SAINT CLOUD MN
56304-0761
US

IV. Provider business mailing address

2015 CHICAGO AVE
MINNEAPOLIS MN
55404-2813
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-9504
  • Fax:
Mailing address:
  • Phone: 612-315-2858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number13522
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: