Provider Demographics
NPI:1568131191
Name:JOHNSON, JACE JORDAN (CPO)
Entity Type:Individual
Prefix:MR
First Name:JACE
Middle Name:JORDAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1484 STEELE RD
Mailing Address - Street 2:
Mailing Address - City:TONTITOWN
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6249
Mailing Address - Country:US
Mailing Address - Phone:918-843-0713
Mailing Address - Fax:
Practice Address - Street 1:429 W CENTERTON BLVD
Practice Address - Street 2:
Practice Address - City:CENTERTON
Practice Address - State:AR
Practice Address - Zip Code:72719-8701
Practice Address - Country:US
Practice Address - Phone:918-843-0713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROPP00271224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist