Provider Demographics
NPI:1770213001
Name:JOHNS, FANNY JERUSHA
Entity Type:Individual
Prefix:
First Name:FANNY
Middle Name:JERUSHA
Last Name:JOHNS
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 1:1785 PARK TRL NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-7039
Mailing Address - Country:US
Mailing Address - Phone:616-322-1713
Mailing Address - Fax:
Practice Address - Street 1:420 COVERED VLG
Practice Address - Street 2:
Practice Address - City:BELDING
Practice Address - State:MI
Practice Address - Zip Code:48809-1665
Practice Address - Country:US
Practice Address - Phone:616-430-2924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor