Healthcare Provider Details

I. General information

NPI: 1649686312
Provider Name (Legal Business Name): MCKINSEY JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 W 1400 N STE A
LOGAN UT
84341-6816
US

IV. Provider business mailing address

1073 N 200 E
LOGAN UT
84341-2306
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-5302
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: