Provider Demographics
NPI:1811415870
Name:JOHNSEN, JANE (LADC)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:JOHNSEN
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S 12TH AVE W STE 1
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2001
Mailing Address - Country:US
Mailing Address - Phone:218-749-2877
Mailing Address - Fax:218-749-6033
Practice Address - Street 1:505 12TH AVE WEST
Practice Address - Street 2:SUITE 1
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792
Practice Address - Country:US
Practice Address - Phone:218-749-2877
Practice Address - Fax:218-749-6033
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304167101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)