Provider Demographics
NPI:1922424407
Name:JOHNSON, ALLEN JEROME
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:JEROME
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ALLEN
Other - Middle Name:JEROME
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LADC
Mailing Address - Street 1:306 E 100TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-5030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14162 COMMERCE AVE NE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-1480
Practice Address - Country:US
Practice Address - Phone:952-447-1117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-09
Last Update Date:2014-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301018101YA0400X
SD99111062101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)