Provider Demographics
NPI:1457474769
Name:JOHNSON, JACI (LCSW)
Entity Type:Individual
Prefix:
First Name:JACI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 SMITH AVE N
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2534
Mailing Address - Country:US
Mailing Address - Phone:651-241-5290
Mailing Address - Fax:651-241-5140
Practice Address - Street 1:225 SMITH AVE N
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2534
Practice Address - Country:US
Practice Address - Phone:651-241-5290
Practice Address - Fax:651-241-5140
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN153481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical