Healthcare Provider Details

I. General information

NPI: 1104463694
Provider Name (Legal Business Name): KIMBERLIE JO JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2019
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1881 N 1120 W
PROVO UT
84604-1180
US

IV. Provider business mailing address

1881 N 1120 W
PROVO UT
84604-1180
US

V. Phone/Fax

Practice location:
  • Phone: 435-248-2089
  • Fax: 801-207-5104
Mailing address:
  • Phone: 435-248-2089
  • Fax: 801-207-5104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: