Healthcare Provider Details

I. General information

NPI: 1528460003
Provider Name (Legal Business Name): JENNIFER JOHANNESSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 S. BROAD ST.
SACKETS HARBOR NY
13685-0290
US

IV. Provider business mailing address

PO BOX 290
SACKETS HARBOR NY
13685-0290
US

V. Phone/Fax

Practice location:
  • Phone: 315-646-3419
  • Fax: 315-646-1038
Mailing address:
  • Phone: 315-646-3419
  • Fax: 315-646-1038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number526638-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: