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General NPI Number Information
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NPI Number | 1902055668
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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 | 09/17/2008
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Last Update Date | 09/17/2008
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Provider Practice Location Address
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Address Line | 211 6TH ST
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City | WALKER
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State | MN
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Zip | 56484-0955
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Country | US
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Telephone | 218-541-1100
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Fax | 218-547-1120
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Provider Business Mailing Address
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Address Line | PO BOX 955
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City | WALKER
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State | MN
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Zip | 56484-0955
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Country | US
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Telephone | 218-541-1100
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Fax | 218-547-1120
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | JAN J JOHNSON
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Credential | LADC
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Telephone | 218-682-2991
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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