Provider Demographics
NPI:1588203830
Name:JOHNSON, KIANA KIMMJO
Entity Type:Individual
Prefix:
First Name:KIANA
Middle Name:KIMMJO
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 1:18643 JONESBORO CT
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-6500
Mailing Address - Country:US
Mailing Address - Phone:612-708-9043
Mailing Address - Fax:
Practice Address - Street 1:18643 JONESBORO CT
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-6500
Practice Address - Country:US
Practice Address - Phone:612-708-9043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-04
Last Update Date:2020-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305587101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)