Provider Demographics
NPI:1023346012
Name:JOHNSON, JORDAN LEE (MA, LPC, LPCC)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MA, LPC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6303 OSGOOD AVE N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6101
Mailing Address - Country:US
Mailing Address - Phone:651-383-4800
Mailing Address - Fax:651-383-4801
Practice Address - Street 1:6303 OSGOOD AVE N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6101
Practice Address - Country:US
Practice Address - Phone:651-383-4800
Practice Address - Fax:651-383-4801
Is Sole Proprietor?:No
Enumeration Date:2009-12-02
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4851-125101YP2500X
MNCC00629101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1023346012Medicaid
WI1023346012Medicaid