Healthcare Provider Details

I. General information

NPI: 1063338333
Provider Name (Legal Business Name): JACOB T JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 YELLOWSTONE STREET
FORT PIERRE SD
57532
US

IV. Provider business mailing address

1820 RAND RD
RAPID CITY SD
57702-9393
US

V. Phone/Fax

Practice location:
  • Phone: 605-280-4481
  • Fax:
Mailing address:
  • Phone: 605-280-4481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P1400X
TaxonomyPain Management Pharmacist
License Number22ESTC0839
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code1835P1400X
TaxonomyPain Management Pharmacist
License Number25ESTC1701
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code1835P1400X
TaxonomyPain Management Pharmacist
License Number22ESTC7355
License Number StateSD
# 4
Primary TaxonomyN
Taxonomy Code1835P1400X
TaxonomyPain Management Pharmacist
License Number22ESTC5017
License Number StateSD
# 5
Primary TaxonomyY
Taxonomy Code1835P1400X
TaxonomyPain Management Pharmacist
License Number22ESTC8676
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: