Provider Demographics
NPI:1467229666
Name:JOHNSON, JACK ALEXANDER
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ALEXANDER
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 1:5032 WISTFUL VISTA DR
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-6922
Mailing Address - Country:US
Mailing Address - Phone:515-783-5022
Mailing Address - Fax:
Practice Address - Street 1:1200 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1406
Practice Address - Country:US
Practice Address - Phone:515-241-6962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program