Healthcare Provider Details

I. General information

NPI: 1730581828
Provider Name (Legal Business Name): JENNA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA HOFFERT

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3315 UNIVERSITY DR LEWIS GOODHOUSE WELLNESS CENTER
BISMARCK ND
58504-7565
US

IV. Provider business mailing address

3315 UNIVERSITY DR LEWIS GOODHOUSE WELLNESS CENTER
BISMARCK ND
58504-7565
US

V. Phone/Fax

Practice location:
  • Phone: 701-255-3285
  • Fax: 701-530-0645
Mailing address:
  • Phone: 701-255-3285
  • Fax: 701-530-0645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number748-4-15-13A
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: