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General NPI Number Information
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NPI Number | 1982120895
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Entity Type | Individual
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Provider Name | JACOB LYNN JOHNSON DMD
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Gender | Male
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Dates
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Enumeration Date | 08/22/2017
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Last Update Date | 08/20/2023
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Provider Practice Location Address
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Address Line | BLDG 1200, 149G W HART ST
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City | SHEPPARD AFB
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State | TX
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Zip | 76311-7631
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Country | US
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Telephone | 940-676-4412
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Fax |
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Provider Business Mailing Address
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Address Line | 5021 TAFT BLVD APT 3302
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City | WICHITA FALLS
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State | TX
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Zip | 76308-5391
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Country | US
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Telephone | 701-339-1678
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 2017020610
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 34858
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 171000000X
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Taxonomy Name | Military Health Care Provider
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License Number | 34858
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License Number State | TX
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