Healthcare Provider Details

I. General information

NPI: 1568818672
Provider Name (Legal Business Name): JAYVIAN JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2016
Last Update Date: 05/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 E 11TH ST
LITTLE ROCK AR
72202-4320
US

IV. Provider business mailing address

PO BOX 166415
LITTLE ROCK AR
72216-6415
US

V. Phone/Fax

Practice location:
  • Phone: 501-425-8174
  • Fax:
Mailing address:
  • Phone: 501-425-8174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number46-0763339
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: