Healthcare Provider Details

I. General information

NPI: 1578301461
Provider Name (Legal Business Name): JERRICK JOHNSON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COMMERCIAL PARK CT APT 145
MAUMELLE AR
72113-6992
US

IV. Provider business mailing address

100 COMMERCIAL PARK CT APT 145
MAUMELLE AR
72113-6992
US

V. Phone/Fax

Practice location:
  • Phone: 501-416-8867
  • Fax:
Mailing address:
  • Phone: 501-416-8867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number11221112610
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code163WR0400X
TaxonomyRehabilitation Registered Nurse
License Number218478
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: