Provider Demographics
NPI:1508145012
Name:JOHNSON, JUDITH A
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 75
Mailing Address - Street 2:
Mailing Address - City:MELVIN
Mailing Address - State:IA
Mailing Address - Zip Code:51350-0075
Mailing Address - Country:US
Mailing Address - Phone:712-476-5245
Mailing Address - Fax:712-476-9621
Practice Address - Street 1:1905 10TH ST
Practice Address - Street 2:
Practice Address - City:ROCK VALLEY
Practice Address - State:IA
Practice Address - Zip Code:51247-1630
Practice Address - Country:US
Practice Address - Phone:712-476-5245
Practice Address - Fax:712-476-9621
Is Sole Proprietor?:No
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001307101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health