Provider Demographics
NPI:1063247096
Name:JOHNSON, JANA
Entity type:Individual
Prefix:MS
First Name:JANA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 ALVA ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-9792
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:JLN TENGKULAK KELOD, NO. 1
Practice Address - Street 2:ANANDA VIHAR VILLAS
Practice Address - City:KEMENUH, SUKAWATI
Practice Address - State:BALI
Practice Address - Zip Code:80571
Practice Address - Country:ID
Practice Address - Phone:646-652-6227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral