Provider Demographics
NPI:1417311465
Name:LOE-JOHNSON, KJELLANN (LAPC)
Entity Type:Individual
Prefix:
First Name:KJELLANN
Middle Name:
Last Name:LOE-JOHNSON
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:KJELLANN
Other - Middle Name:
Other - Last Name:LOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2624 9TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2350
Mailing Address - Country:US
Mailing Address - Phone:701-298-4500
Mailing Address - Fax:701-298-4400
Practice Address - Street 1:2624 9TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2350
Practice Address - Country:US
Practice Address - Phone:701-298-4500
Practice Address - Fax:701-298-4400
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND782-4-1-14A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional