Healthcare Provider Details

I. General information

NPI: 1194144105
Provider Name (Legal Business Name): JACOB HUNTER JOHNSON OT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 05/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7555 BARNETT WAY
POWELL TN
37849-3565
US

IV. Provider business mailing address

8823 PRODUCTION LN
OOLTEWAH TN
37363-6511
US

V. Phone/Fax

Practice location:
  • Phone: 865-938-3556
  • Fax: 865-938-3558
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-954-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number15590
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10088
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number4979
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: