Healthcare Provider Details

I. General information

NPI: 1659194546
Provider Name (Legal Business Name): JESSE JOHNSTON MS, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2024
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 E LYON ST
LARAMIE WY
82072-2132
US

IV. Provider business mailing address

2737 NIGHTHAWK DR
LARAMIE WY
82072-1992
US

V. Phone/Fax

Practice location:
  • Phone: 307-223-2172
  • Fax:
Mailing address:
  • Phone: 307-223-2172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-2561
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-0024289
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: