Provider Demographics
NPI:1801859996
Name:JOHNSON, JACK LEEGON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:LEEGON
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:560 W MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-3629
Mailing Address - Country:US
Mailing Address - Phone:972-436-9797
Mailing Address - Fax:972-436-9790
Practice Address - Street 1:560 W MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-3629
Practice Address - Country:US
Practice Address - Phone:972-436-9797
Practice Address - Fax:972-436-9790
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXH5576207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0047LPOtherBLUE CROSS BLUE SHIELD
TXB30054Medicare UPIN
TX00721XMedicare ID - Type UnspecifiedMEDICARE
TX0047LPOtherBLUE CROSS BLUE SHIELD