Provider Demographics
NPI:1578640694
Name:JOHNSON, KERRY LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:LEE
Last Name:JOHNSON
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 1:14859 ENERGY WAY
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-5763
Mailing Address - Country:US
Mailing Address - Phone:952-432-3333
Mailing Address - Fax:952-432-4444
Practice Address - Street 1:14859 ENERGY WAY
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-5763
Practice Address - Country:US
Practice Address - Phone:952-432-3333
Practice Address - Fax:952-432-4444
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2241111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN24165JOOtherBCBS MN ID NUMBER
MNT39893Medicare UPIN
MN24165JOOtherBCBS MN ID NUMBER