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General NPI Number Information
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NPI Number | 1700300373
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Entity Type | Individual
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Provider Name | JACLYN JOHNSON
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Gender | Female
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Dates
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Enumeration Date | 07/26/2017
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Last Update Date | 11/14/2018
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Provider Practice Location Address
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Address Line | 14239 W BELL RD STE 216
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City | SURPRISE
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State | AZ
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Zip | 85374-2482
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Country | US
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Telephone | 602-955-1000
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Fax |
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Provider Business Mailing Address
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Address Line | 4129 S MEADOWS RD APT 1628
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City | SANTA FE
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State | NM
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Zip | 87507-2719
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Country | US
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Telephone |
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Fax |
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT.0003337
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License Number State | CO
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