MEDICARE: JENNA MICHELLE JOHNSON-CLARK LPCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	3313	MN

General Provider Information

NPI Number	:	1083401517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA MICHELLE JOHNSON-CLARK LPCC

Provider Business Mailing Address
First Line	:	1492 HAZEL ST N
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55119-4227
Country	:	US
Telephone Number	:	317-607-2121
Fax Number	:

Provider Business Practice Location Address
First Line	:	1205 GRAND AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-2634
Country	:	US
Telephone Number	:	317-607-2121
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2025
Last Update Date	:	02/12/2026

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