Provider Demographics
NPI:1073083457
Name:JOHNSON, JADE TAYLIR (ATC)
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:TAYLIR
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NE
Mailing Address - Zip Code:68787-2210
Mailing Address - Country:US
Mailing Address - Phone:715-566-3288
Mailing Address - Fax:
Practice Address - Street 1:1111 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NE
Practice Address - Zip Code:68787-1181
Practice Address - Country:US
Practice Address - Phone:402-375-7162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7772081S0010X, 2083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine