Healthcare Provider Details

I. General information

NPI: 1689539595
Provider Name (Legal Business Name): JEREMIAH ELISHA JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2025
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MAIN ST S
MINOT ND
58701-3914
US

IV. Provider business mailing address

100 MAIN ST S
MINOT ND
58701-3914
US

V. Phone/Fax

Practice location:
  • Phone: 904-303-4606
  • Fax:
Mailing address:
  • Phone: 904-303-4606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: