Healthcare Provider Details

I. General information

NPI: 1235401514
Provider Name (Legal Business Name): JOHNSON VISION DEVELOPMENT CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 GREYSTONE SQUARE
JACKSON TN
38305
US

IV. Provider business mailing address

1012 GREYSTONE SQUARE
JACKSON TN
38305
US

V. Phone/Fax

Practice location:
  • Phone: 731-660-1100
  • Fax: 731-660-0688
Mailing address:
  • Phone: 731-660-1100
  • Fax: 731-660-0688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. PAULA JOHNSON-WYATT
Title or Position: OWNER/OPTOMETRIST
Credential: OD
Phone: 731-660-1100