Provider Demographics
NPI:1285837948
Name:JOHNSON, JEAN ELIZABETH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8362 TAMARACK VLG
Mailing Address - Street 2:SUITE 119, BOX 172
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3392
Mailing Address - Country:US
Mailing Address - Phone:651-402-6209
Mailing Address - Fax:651-905-1815
Practice Address - Street 1:1301 CORPORATE CENTER DR
Practice Address - Street 2:SUITE 116
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-1298
Practice Address - Country:US
Practice Address - Phone:651-905-1814
Practice Address - Fax:651-905-1815
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4356101YM0800X, 103T00000X, 103TA0700X, 103TB0200X, 103TC0700X, 103TC2200X, 103TF0000X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities