Healthcare Provider Details

I. General information

NPI: 1568131191
Provider Name (Legal Business Name): JACE JORDAN JOHNSON CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/11/2025
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 W CENTERTON BLVD
CENTERTON AR
72719-8701
US

IV. Provider business mailing address

1484 STEELE RD
TONTITOWN AR
72762-6249
US

V. Phone/Fax

Practice location:
  • Phone: 918-843-0713
  • Fax:
Mailing address:
  • Phone: 918-843-0713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224L00000X
TaxonomyPedorthist
License NumberOPP00271
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: