Provider Demographics
NPI:1093920951
Name:JAN JOHNSON
Entity Type:Organization
Organization Name:JAN JOHNSON
Other - Org Name:FIRST STEP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:218-894-0034
Mailing Address - Street 1:518 2ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:STAPLES
Mailing Address - State:MN
Mailing Address - Zip Code:56479-2930
Mailing Address - Country:US
Mailing Address - Phone:218-894-2412
Mailing Address - Fax:218-894-0034
Practice Address - Street 1:201 6TH ST NE
Practice Address - Street 2:
Practice Address - City:STAPLES
Practice Address - State:MN
Practice Address - Zip Code:56479-2431
Practice Address - Country:US
Practice Address - Phone:218-894-0034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1039408-1-CDT101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN437100000OtherMHCP