Healthcare Provider Details

I. General information

NPI: 1538692595
Provider Name (Legal Business Name): JENNA JOHNSON MDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 05/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 7TH ST E
SAINT PAUL MN
55119
US

IV. Provider business mailing address

8718 QUARRY RIDGE LN UNIT D
WOODBURY MN
55125-7523
US

V. Phone/Fax

Practice location:
  • Phone: 651-735-0521
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT80
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: