Healthcare Provider Details

I. General information

NPI: 1699584755
Provider Name (Legal Business Name): JACOB REECE JOHNSON DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2025
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3839 W CONGRESS ST STE B
LAFAYETTE LA
70506-6000
US

IV. Provider business mailing address

3839 W CONGRESS ST STE B
LAFAYETTE LA
70506-6000
US

V. Phone/Fax

Practice location:
  • Phone: 870-826-1511
  • Fax:
Mailing address:
  • Phone: 870-826-1511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7636
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: