=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437202884
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY TODD JOHNSON ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 720 4TH AVE S 214 HALENBECK HALL
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56301-4442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-308-2503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 332 RIVERSIDE DR NE
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56304-0345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-656-1453
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 1088
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------