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General NPI Number Information
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NPI Number | 1174873723
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Entity Type | Individual
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Provider Name | JACOB DARRELL JOHNSON DPT
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Gender | Male
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Dates
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Enumeration Date | 09/11/2012
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Last Update Date | 09/11/2012
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Provider Practice Location Address
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Address Line | 1515 NORTH CENTER STREET SUITE 5
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City | LONOKE
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State | AR
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Zip | 72086
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Country | US
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Telephone | 501-676-5540
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Fax | 501-676-6499
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Provider Business Mailing Address
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Address Line | 1515 NORTH CENTER STREET SUITE 5
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City | LONOKE
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State | AR
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Zip | 72086
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Country | US
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Telephone | 501-676-5540
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Fax | 501-676-6499
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT 3506
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License Number State | AR
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