Provider Demographics
NPI:1225403033
Name:JOHNSON, WILL JOHN
Entity Type:Individual
Prefix:
First Name:WILL
Middle Name:JOHN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MEADE ST
Mailing Address - Street 2:
Mailing Address - City:WHITEWOOD
Mailing Address - State:SD
Mailing Address - Zip Code:57793-3054
Mailing Address - Country:US
Mailing Address - Phone:605-717-2428
Mailing Address - Fax:605-717-2491
Practice Address - Street 1:1001 MEADE ST
Practice Address - Street 2:
Practice Address - City:WHITEWOOD
Practice Address - State:SD
Practice Address - Zip Code:57793-3054
Practice Address - Country:US
Practice Address - Phone:605-717-2428
Practice Address - Fax:605-717-2491
Is Sole Proprietor?:No
Enumeration Date:2015-12-04
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1277111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor