Provider Demographics
NPI:1558377796
Name:HARTNELL, JOHNA C (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHNA
Middle Name:C
Last Name:HARTNELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JOHNA
Other - Middle Name:C
Other - Last Name:GERASCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX J
Mailing Address - Street 2:PHS INDIAN HEALTH SERVICE, DIR. BEHAVIORAL HEALTH
Mailing Address - City:FORT YATES
Mailing Address - State:ND
Mailing Address - Zip Code:58538-0527
Mailing Address - Country:US
Mailing Address - Phone:701-854-8276
Mailing Address - Fax:701-854-3844
Practice Address - Street 1:10 NORTH RIVER ROAD
Practice Address - Street 2:PHS INDIAN HEALTH SERVICE
Practice Address - City:FORT YATES
Practice Address - State:ND
Practice Address - Zip Code:58538-0797
Practice Address - Country:US
Practice Address - Phone:701-854-3831
Practice Address - Fax:701-854-3844
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1129103T00000X
WI1116-57103T00000X, 103T00000X
NM0035103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND81613Medicaid
WI000684106OtherMEDICARE
NDHSZI31ZJSBOtherINDIAN HEALTH SERVICE
WI39035300Medicaid