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General NPI Number Information
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NPI Number | 1912165218
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Entity Type | Organization
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Legal Business Name | JACK L. JOHNSON JR., M.D., P.A.
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Dates
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Enumeration Date | 05/23/2008
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Last Update Date | 11/21/2008
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Provider Practice Location Address
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Address Line | 560 W MAIN ST SUITE 100
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City | LEWISVILLE
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State | TX
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Zip | 75057-3629
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Country | US
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Telephone | 972-436-9797
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Fax | 972-436-9790
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Provider Business Mailing Address
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Address Line | 560 W MAIN ST SUITE 100
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City | LEWISVILLE
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State | TX
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Zip | 75057-3629
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Country | US
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Telephone | 972-436-9797
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Fax | 972-436-9790
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | DR. JACK L. JOHNSON JR.
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Credential | M.D.
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Telephone | 972-436-9797
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | H5576
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License Number State | TX
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