Healthcare Provider Details

I. General information

NPI: 1073083457
Provider Name (Legal Business Name): JADE TAYLIR JOHNSON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2018
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MAIN ST
WAYNE NE
68787-1181
US

IV. Provider business mailing address

521 E 6TH ST
WAYNE NE
68787-2210
US

V. Phone/Fax

Practice location:
  • Phone: 402-375-7162
  • Fax:
Mailing address:
  • Phone: 715-566-3288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number777
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number777
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: