Provider Demographics
NPI:1750186557
Name:JOHNSON, SAMANTHA JORDAN
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JORDAN
Last Name:JOHNSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 OKEEFFE AVE APT 150
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-4142
Mailing Address - Country:US
Mailing Address - Phone:608-513-3080
Mailing Address - Fax:
Practice Address - Street 1:1051 OKEEFFE AVE APT 150
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-4142
Practice Address - Country:US
Practice Address - Phone:608-513-3080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-17
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8297226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional