Provider Demographics
NPI:1366221392
Name:JOHNSON, CLINTON GABRIEL JR
Entity type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:GABRIEL
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 UNIVERSITY AVE W STE S137
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-2891
Mailing Address - Country:US
Mailing Address - Phone:320-339-6553
Mailing Address - Fax:
Practice Address - Street 1:1821 UNIVERSITY AVE W STE S137
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-2891
Practice Address - Country:US
Practice Address - Phone:320-339-6553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA486630300Medicaid