Provider Demographics
NPI:1710031117
Name:JOHNSON, MARY J (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23624 ST. FRANCIS BLVD., STE #1
Mailing Address - Street 2:
Mailing Address - City:ST FRANCIS
Mailing Address - State:MN
Mailing Address - Zip Code:55070
Mailing Address - Country:US
Mailing Address - Phone:763-753-3126
Mailing Address - Fax:763-753-2808
Practice Address - Street 1:23624 ST FRANCIS BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ST FRANCIS
Practice Address - State:MN
Practice Address - Zip Code:55070-0399
Practice Address - Country:US
Practice Address - Phone:763-753-3126
Practice Address - Fax:763-753-2808
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2663111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
231258OtherCCMI
4K009J0OtherBCBS INDIVIDUAL
4K008J0OtherBCBS CLINIC
0125OtherHSM
4440078OtherMEDICA
MN817228500Medicaid
231258OtherCCMI
4K009J0OtherBCBS INDIVIDUAL