Healthcare Provider Details

I. General information

NPI: 1528987971
Provider Name (Legal Business Name): JEANETTE M. JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 COOPER AVE
GRAFTON ND
58237-1512
US

IV. Provider business mailing address

516 COOPER AVE
GRAFTON ND
58237-1512
US

V. Phone/Fax

Practice location:
  • Phone: 701-350-5110
  • Fax: 701-352-5060
Mailing address:
  • Phone: 701-350-5110
  • Fax: 701-352-5060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: