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General NPI Number Information
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NPI Number | 1093920951
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Entity Type | Organization
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Legal Business Name | JAN JOHNSON
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Dates
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Enumeration Date | 05/14/2007
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Last Update Date | 07/16/2008
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Provider Practice Location Address
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Address Line | 201 6TH ST NE
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City | STAPLES
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State | MN
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Zip | 56479-2431
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Country | US
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Telephone | 218-894-0034
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Fax |
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Provider Business Mailing Address
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Address Line | 518 2ND AVE NE
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City | STAPLES
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State | MN
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Zip | 56479-2930
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Country | US
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Telephone | 218-894-2412
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Fax | 218-894-0034
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Authorized Official
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Title or Position | DIRECTOR
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Name | MS. JAN J JOHNSON
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Credential | LADC
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Telephone | 218-894-0034
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 1039408-1-CDT
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License Number State | MN
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