Provider Demographics
NPI:1730318882
Name:JOHNSON, MARJEAN CAROL
Entity Type:Individual
Prefix:
First Name:MARJEAN
Middle Name:CAROL
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 1:602 SW MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-4515
Mailing Address - Country:US
Mailing Address - Phone:541-753-9217
Mailing Address - Fax:541-753-2672
Practice Address - Street 1:602 SW MADISON AVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-4515
Practice Address - Country:US
Practice Address - Phone:541-753-9217
Practice Address - Fax:541-753-2672
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL33141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical