Provider Demographics
NPI:1447912316
Name:JOHNSON, JACLYN RACHEL (MA, LPCC, LADC)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:RACHEL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, LPCC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 BERKSHIRE LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-3813
Mailing Address - Country:US
Mailing Address - Phone:763-203-9568
Mailing Address - Fax:
Practice Address - Street 1:4100 BERKSHIRE LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-3813
Practice Address - Country:US
Practice Address - Phone:763-203-9568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-08
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306063101YA0400X
MNCC04220101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)