Provider Demographics
NPI:1740606227
Name:JOHNSON, JEANNE ADELAIDE (LADC, BA, ICADC, LAC)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:ADELAIDE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LADC, BA, ICADC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8609 LYNDALE AVE S
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-2754
Mailing Address - Country:US
Mailing Address - Phone:952-358-1009
Mailing Address - Fax:952-881-1093
Practice Address - Street 1:8609 LYNDALE AVE S
Practice Address - Street 2:SUITE 110
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-2754
Practice Address - Country:US
Practice Address - Phone:952-358-1009
Practice Address - Fax:952-881-1093
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-09
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300969101YA0400X
SD9605694101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)