Healthcare Provider Details

I. General information

NPI: 1225087588
Provider Name (Legal Business Name): WAYNE C JOHNSON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 ELLIS AVE
JACKSON MS
39209-6256
US

IV. Provider business mailing address

PO BOX 746085
ATLANTA GA
30374-6085
US

V. Phone/Fax

Practice location:
  • Phone: 601-533-7016
  • Fax: 769-333-9150
Mailing address:
  • Phone: 773-352-1515
  • Fax: 312-929-0373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13895
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: