Provider Demographics
NPI:1528549284
Name:JOHNSON, JESSE TAYLOR (MS, LPCC, NCC)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:TAYLOR
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MS, LPCC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:
Practice Address - Street 1:817 MAIN ST N
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1275
Practice Address - Country:US
Practice Address - Phone:763-325-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional