Provider Demographics
NPI:1639916265
Name:JOHNSON, JEANIE (LICSW)
Entity type:Individual
Prefix:
First Name:JEANIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 VALLEY PINE CIR
Mailing Address - Street 2:
Mailing Address - City:INTERNATIONAL FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56649-2179
Mailing Address - Country:US
Mailing Address - Phone:218-283-3406
Mailing Address - Fax:
Practice Address - Street 1:1902 VALLEY PINE CIR
Practice Address - Street 2:
Practice Address - City:INTERNATIONAL FALLS
Practice Address - State:MN
Practice Address - Zip Code:56649-2179
Practice Address - Country:US
Practice Address - Phone:218-283-3406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty