Provider Demographics
NPI:1407426224
Name:DOE, JOHNSON CHESTER JR
Entity Type:Individual
Prefix:
First Name:JOHNSON
Middle Name:CHESTER
Last Name:DOE
Suffix:JR
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 1:5523 102ND AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-2074
Mailing Address - Country:US
Mailing Address - Phone:763-639-2890
Mailing Address - Fax:
Practice Address - Street 1:5523 102ND AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-2074
Practice Address - Country:US
Practice Address - Phone:763-639-2890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide