Healthcare Provider Details

I. General information

NPI: 1538552013
Provider Name (Legal Business Name): AMANDA JO JOHNSTON BS, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA JO WILCOX BS, LAC

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 2ND AVE W
WILLISTON ND
58801-5218
US

IV. Provider business mailing address

1500 14TH ST W STE 290
WILLISTON ND
58801-4078
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-4600
  • Fax:
Mailing address:
  • Phone: 701-751-0299
  • Fax: 701-713-3299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number101YA0400X
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1980
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: