Provider Demographics
NPI:1427029750
Name:JOHANSEN, J R (DC)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:R
Last Name:JOHANSEN
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 1:638 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE
Mailing Address - State:IA
Mailing Address - Zip Code:51012-1860
Mailing Address - Country:US
Mailing Address - Phone:712-225-3633
Mailing Address - Fax:
Practice Address - Street 1:638 N 2ND ST
Practice Address - Street 2:
Practice Address - City:CHEROKEE
Practice Address - State:IA
Practice Address - Zip Code:51012-1860
Practice Address - Country:US
Practice Address - Phone:712-225-3633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04017111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0017418Medicaid
01741Medicare ID - Type Unspecified
IA0017418Medicaid