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Mrs. Jacqueline S Johanson

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NPI Number Detailed Information

Provider Information:

Name: Mrs. Jacqueline S Johanson
Gender: F
Provider License Number If Given: 5601008301

NPI Information:

NPI: 1952304982
Entity Type
(Individual or Organization):
1-ind
Enumeration Date: 5/23/2005

Last Update Date: 2/6/2018

Provider Business Mailing Address:

Address: 100 MICHIGAN ST NE MC 845
Grand Rapids, MI 49503
Phone Number:
Fax Number:

Provider Business Practice Location Address:

Address: 230 MICHIGAN ST NE STE 230
Grand Rapids, MI 49503
Phone Number: 4043553161
Fax Number: 4043551353

Provider Taxonomy:

Primary: 363A00000X
Secondary (if any):
State: MI

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