MEDICARE: JESSICA MICHELLE JOHNSON LMFT

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	106H00000X	Marriage & Family Therapist	3676	MN

General Provider Information

NPI Number	:	1255667317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA MICHELLE JOHNSON LMFT

Provider Business Mailing Address
First Line	:	6402 RIVER MILL DR
Second Line	:
City	:	MONTICELLO
State	:	MN
Zip	:	55362-3607
Country	:	US
Telephone Number	:	612-280-6326
Fax Number	:

Provider Business Practice Location Address
First Line	:	2708 119TH AVE NW
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55433-2912
Country	:	US
Telephone Number	:	612-704-9396
Fax Number	:

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

Provider Enumeration Date	:	10/26/2009
Last Update Date	:	08/30/2019

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