Healthcare Provider Details

I. General information

NPI: 1760295752
Provider Name (Legal Business Name): JENNIFER EILEEN JOHNSON LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2025
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3221 32ND AVE S STE 700
GRAND FORKS ND
58201-6075
US

IV. Provider business mailing address

406 9TH ST NW
FOSSTON MN
56542-1019
US

V. Phone/Fax

Practice location:
  • Phone: 701-335-4380
  • Fax:
Mailing address:
  • Phone: 218-308-4647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number31892
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: