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General NPI Number Information
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NPI Number | 1740375740
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Entity Type | Individual
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Provider Name | JODY REIS-JOHNSON M.DIV.,MSW, LICSW
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Gender | Female
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Dates
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Enumeration Date | 10/04/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3450 OLEARY LN
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City | EAGAN
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State | MN
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Zip | 55123-2340
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Country | US
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Telephone | 651-454-0114
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Fax | 651-454-3492
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Provider Business Mailing Address
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Address Line | 441 JUNIPER CT
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City | MAHTOMEDI
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State | MN
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Zip | 55115-1558
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 06627
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License Number State | MN
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