Healthcare Provider Details

I. General information

NPI: 1285988907
Provider Name (Legal Business Name): JENNIFER J JOHNSON TLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2012
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5815 BROADWAY AVE
GREAT BEND KS
67530-3123
US

IV. Provider business mailing address

5815 BROADWAY AVE
GREAT BEND KS
67530-3123
US

V. Phone/Fax

Practice location:
  • Phone: 620-792-2544
  • Fax: 620-792-7052
Mailing address:
  • Phone: 620-792-2544
  • Fax: 620-792-7052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2769
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: