Provider Demographics
NPI:1760805741
Name:JOHNSON, JARRELL
Entity Type:Individual
Prefix:
First Name:JARRELL
Middle Name:
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 1:7614 SW CHEROKEE AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-6421
Mailing Address - Country:US
Mailing Address - Phone:580-678-6902
Mailing Address - Fax:
Practice Address - Street 1:7614 SW CHEROKEE AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6421
Practice Address - Country:US
Practice Address - Phone:580-678-6902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor