Provider Demographics
NPI:1477803435
Name:JOHNSON, JENNIFER SUSAN (MA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUSAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7036 HIGHOVER CT S
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-7569
Mailing Address - Country:US
Mailing Address - Phone:612-210-1748
Mailing Address - Fax:952-470-5175
Practice Address - Street 1:1772 STEIGER LAKE LN
Practice Address - Street 2:#220
Practice Address - City:VICTORIA
Practice Address - State:MN
Practice Address - Zip Code:55386-7723
Practice Address - Country:US
Practice Address - Phone:952-443-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist