Provider Demographics
NPI:1538552013
Name:JOHNSTON, AMANDA JO (BS, LAC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:JO
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:BS, LAC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JO
Other - Last Name:WILCOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS, LAC
Mailing Address - Street 1:1500 14TH ST W STE 290
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-4078
Mailing Address - Country:US
Mailing Address - Phone:701-751-0299
Mailing Address - Fax:701-713-3299
Practice Address - Street 1:1500 14TH ST W STE 290
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-4078
Practice Address - Country:US
Practice Address - Phone:701-751-0299
Practice Address - Fax:701-713-3299
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT101YA0400X101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor