Provider Demographics
NPI:1992223697
Name:JOHNSON, JANE
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:JOHNSON
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 1:643 BIRCH LN
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-3226
Mailing Address - Country:US
Mailing Address - Phone:218-236-1783
Mailing Address - Fax:
Practice Address - Street 1:2405 8TH ST S STE 200
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-4200
Practice Address - Country:US
Practice Address - Phone:218-380-7357
Practice Address - Fax:218-331-4867
Is Sole Proprietor?:No
Enumeration Date:2017-09-01
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11062104100000X
ND37991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker