MEDICARE: JOHNSON CHIROPRACTIC CLINIC, P.C.

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	111N00000X	Chiropractor	038004465	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3715466	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1669593315
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHNSON CHIROPRACTIC CLINIC, P.C.

Provider Business Mailing Address
First Line	:	109 S BURR BLVD
Second Line	:
City	:	KEWANEE
State	:	IL
Zip	:	61443-2219
Country	:	US
Telephone Number	:	309-852-2885
Fax Number	:	309-854-6410

Provider Business Practice Location Address
First Line	:	109 S BURR BLVD
Second Line	:
City	:	KEWANEE
State	:	IL
Zip	:	61443-2219
Country	:	US
Telephone Number	:	309-852-2885
Fax Number	:	309-854-6410

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JEFFREY W. JOHNSON
Credential	:	D.C.
Telephone Number	:	309-852-2885

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	09/23/2024

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