Provider Demographics
NPI:1740375740
Name:REIS-JOHNSON, JODY (MDIV,MSW, LICSW)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:REIS-JOHNSON
Suffix:
Gender:F
Credentials:MDIV,MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 JUNIPER CT
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115-1558
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3450 OLEARY LN
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-2340
Practice Address - Country:US
Practice Address - Phone:651-454-0114
Practice Address - Fax:651-454-3492
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN066271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN157857000OtherMN CARE
FM62-76634OtherUBH
MNHP27073OtherHEALTHPARTNERS
MN599K6JOOtherBCBS
MNHP27073OtherHEALTHPARTNERS