Healthcare Provider Details

I. General information

NPI: 1992223697
Provider Name (Legal Business Name): JANE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2017
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 8TH ST S STE 200
MOORHEAD MN
56560-4200
US

IV. Provider business mailing address

643 BIRCH LN
MOORHEAD MN
56560-3226
US

V. Phone/Fax

Practice location:
  • Phone: 218-380-7357
  • Fax: 218-331-4867
Mailing address:
  • Phone: 218-236-1783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number11062
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3799
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: