Provider Demographics
NPI:1780341156
Name:JOHNSON, KATHLEEN JACKSON (LPC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:JACKSON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:1505 5TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1539
Mailing Address - Country:US
Mailing Address - Phone:701-232-8905
Mailing Address - Fax:
Practice Address - Street 1:1202 WESTRAC DR S STE 200
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2356
Practice Address - Country:US
Practice Address - Phone:701-280-9545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-20
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1165-10-15-21A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional