Provider Demographics
NPI:1043547227
Name:JOHNSON, JAN M (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JAN
Other - Middle Name:M
Other - Last Name:ALWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1401 EAST FIRST STREET
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805
Mailing Address - Country:US
Mailing Address - Phone:218-728-4404
Mailing Address - Fax:218-728-4404
Practice Address - Street 1:4123 E LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2255
Practice Address - Country:US
Practice Address - Phone:612-729-0340
Practice Address - Fax:612-729-2616
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling