Provider Demographics
NPI:1841230869
Name:JOHNSON, DEBRA JO (NP)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:JO
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:30 W 107TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-5502
Mailing Address - Country:US
Mailing Address - Phone:952-881-8649
Mailing Address - Fax:612-863-2596
Practice Address - Street 1:2545 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4522
Practice Address - Country:US
Practice Address - Phone:612-863-4876
Practice Address - Fax:612-863-2596
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR087208-9363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health