Provider Demographics
NPI:1093713760
Name:JOHNSON, JEFFREY WILLIAM (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:WILLIAM
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 S BURR BLVD
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-2219
Mailing Address - Country:US
Mailing Address - Phone:309-852-2885
Mailing Address - Fax:309-854-6410
Practice Address - Street 1:109 S BURR BLVD
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-2219
Practice Address - Country:US
Practice Address - Phone:309-852-2885
Practice Address - Fax:309-854-6410
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT78276Medicare UPIN
ILK48375Medicare PIN