MEDICARE: JADE TAYLIR JOHNSON ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2081S0010X	Sports Medicine (Physical Medicine & Rehabilitation) Physician	777	NE
2	2083S0010X	Sports Medicine (Preventive Medicine) Physician	777	NE

General Provider Information

NPI Number	:	1073083457
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JADE TAYLIR JOHNSON ATC

Provider Business Mailing Address
First Line	:	521 E 6TH ST
Second Line	:
City	:	WAYNE
State	:	NE
Zip	:	68787-2210
Country	:	US
Telephone Number	:	715-566-3288
Fax Number	:

Provider Business Practice Location Address
First Line	:	1111 MAIN ST
Second Line	:
City	:	WAYNE
State	:	NE
Zip	:	68787-1181
Country	:	US
Telephone Number	:	402-375-7162
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2018
Last Update Date	:	11/28/2018

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Directions to “ JADE TAYLIR JOHNSON ATC” Practice Location

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