Provider Demographics
NPI:1760680797
Name:JOHNSON, JODY A (LCSW)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 N LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68801-5969
Mailing Address - Country:US
Mailing Address - Phone:402-225-6360
Mailing Address - Fax:402-988-1565
Practice Address - Street 1:308 N LOCUST ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-5969
Practice Address - Country:US
Practice Address - Phone:402-225-6360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8325101YM0800X
NE1238101YM0800X
IA111283101YM0800X
NE21661041C0700X
NE13381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025173100Medicaid
NE10025173100Medicaid