Healthcare Provider Details

I. General information

NPI: 1497377584
Provider Name (Legal Business Name): JAYLN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2020
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 HIGHWAY 206
CISCO TX
76437-6450
US

IV. Provider business mailing address

801 W 7TH ST
CISCO TX
76437-2957
US

V. Phone/Fax

Practice location:
  • Phone: 254-442-4878
  • Fax:
Mailing address:
  • Phone: 254-433-1119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: