Provider Demographics
NPI:1801867866
Name:JOHANNSEN, JAY CHRISTOPHER (DC)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:CHRISTOPHER
Last Name:JOHANNSEN
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 1:2550 MIDDLE RD STE 400
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-3288
Mailing Address - Country:US
Mailing Address - Phone:563-359-4203
Mailing Address - Fax:563-345-4099
Practice Address - Street 1:2550 MIDDLE RD STE 400
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722
Practice Address - Country:US
Practice Address - Phone:563-359-4203
Practice Address - Fax:563-345-4099
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-29
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06460111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI5444Medicare PIN
IA45192Medicare UPIN
IA45192Medicare UPIN