Provider Demographics
NPI:1508248022
Name:JOHNSON, JACLYN NICOLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 TUNNELTON ST
Mailing Address - Street 2:STE 214
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1452
Mailing Address - Country:US
Mailing Address - Phone:304-329-1989
Mailing Address - Fax:
Practice Address - Street 1:202 TUNNELTON ST
Practice Address - Street 2:STE 214
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1452
Practice Address - Country:US
Practice Address - Phone:304-329-1989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-20
Last Update Date:2015-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4171122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist