Provider Demographics
NPI:1265680722
Name:JOHNSON, KENNETH R JR (PT,DPT,OCS,FAAOMPT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:PT,DPT,OCS,FAAOMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10405 WENTWORTH DR
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75089-8491
Mailing Address - Country:US
Mailing Address - Phone:214-886-5756
Mailing Address - Fax:
Practice Address - Street 1:4065 E PLANO PKWY
Practice Address - Street 2:SUITE 220
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074
Practice Address - Country:US
Practice Address - Phone:214-886-5756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1182217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist