Provider Demographics
NPI:1619289261
Name:JOHNSON, JOSHUA LEE (DC)
Entity Type:Individual
Prefix:
First Name:JOSHUA
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 1:5278 E QUEENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:IL
Mailing Address - Zip Code:61535-9613
Mailing Address - Country:US
Mailing Address - Phone:636-328-4939
Mailing Address - Fax:
Practice Address - Street 1:310 SUSAN DR.
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761
Practice Address - Country:US
Practice Address - Phone:636-328-4939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL27-2998137111N00000X
IL038.011514111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty