Provider Demographics
NPI:1093854945
Name:JOHNSON, JANE POLLOCK
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:POLLOCK
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:MARIE
Other - Last Name:POLLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13403 283RD AVE
Mailing Address - Street 2:
Mailing Address - City:ZIMMERMAN
Mailing Address - State:MN
Mailing Address - Zip Code:55398-9217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9245 QUANTRELLE AVE NE
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55330-0168
Practice Address - Country:US
Practice Address - Phone:763-746-9492
Practice Address - Fax:763-746-3685
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3386106H00000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner