Healthcare Provider Details

I. General information

NPI: 1245118728
Provider Name (Legal Business Name): NIKKI K JOHANSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2025
Last Update Date: 08/23/2025
Certification Date: 08/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 W ALAMEDA RD
POCATELLO ID
83201-6145
US

IV. Provider business mailing address

331 N 400 W
BLACKFOOT ID
83221-5472
US

V. Phone/Fax

Practice location:
  • Phone: 208-237-2233
  • Fax:
Mailing address:
  • Phone: 208-681-8283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: