Provider Demographics
NPI:1144864596
Name:JOHNSON, JAN MARIE (LICSW)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6335 SHERIDAN AVE S
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1009
Mailing Address - Country:US
Mailing Address - Phone:612-799-7247
Mailing Address - Fax:
Practice Address - Street 1:6625 LYNDALE AVE S STE 500
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2691
Practice Address - Country:US
Practice Address - Phone:612-886-3706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical