Provider Demographics
NPI:1396331781
Name:JODY JOHNSON LIFESPAN THERAPY, LLC
Entity type:Organization
Organization Name:JODY JOHNSON LIFESPAN THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:308-380-8555
Mailing Address - Street 1:1107 NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68801-8103
Mailing Address - Country:US
Mailing Address - Phone:308-380-8555
Mailing Address - Fax:
Practice Address - Street 1:308 N LOCUST ST STE 401
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-5901
Practice Address - Country:US
Practice Address - Phone:402-225-6360
Practice Address - Fax:402-998-1565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-19
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty