Provider Demographics
NPI:1043727670
Name:JOHNSON, JENA
Entity type:Individual
Prefix:
First Name:JENA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 101
Mailing Address - Street 2:
Mailing Address - City:FRANCIS CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:54214-0101
Mailing Address - Country:US
Mailing Address - Phone:920-323-6856
Mailing Address - Fax:
Practice Address - Street 1:1616 W BENDER RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-3802
Practice Address - Country:US
Practice Address - Phone:414-228-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2648225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant