Healthcare Provider Details

I. General information

NPI: 1679464119
Provider Name (Legal Business Name): JAYDEN JACK JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2025
Last Update Date: 07/12/2025
Certification Date: 07/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 5TH AVE S APT F6
BROOKINGS SD
57006-3340
US

IV. Provider business mailing address

527 5TH AVE S APT F6
BROOKINGS SD
57006-3340
US

V. Phone/Fax

Practice location:
  • Phone: 605-924-0521
  • Fax:
Mailing address:
  • Phone: 605-924-0521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberE3904089
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberE3904089
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: