MEDICARE: JACKIE C JOHNS DMD

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	1223G0001X	General Practice Dentistry	DN9243	FL

General Provider Information

NPI Number	:	1447473285
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE C JOHNS DMD

Provider Business Mailing Address
First Line	:	2100 45TH STREET
Second Line	:	- SUITE A-8
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407
Country	:	US
Telephone Number	:	561-842-5619
Fax Number	:	561-844-4085

Provider Business Practice Location Address
First Line	:	2100 45TH STREET
Second Line	:	- SUITE A-8
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407
Country	:	US
Telephone Number	:	561-842-5619
Fax Number	:	561-844-4085

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

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	05/11/2022

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