Provider Demographics
NPI:1174512461
Name:JOHNSEN, JOHN J (LAT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:JOHNSEN
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1570 MIDWAY PL
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1165
Mailing Address - Country:US
Mailing Address - Phone:920-720-1784
Mailing Address - Fax:
Practice Address - Street 1:800 ALGOMA BLVD
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-3551
Practice Address - Country:US
Practice Address - Phone:920-424-3225
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer