Provider Demographics
NPI:1851383491
Name:JOHNSON, MARY JO (DC)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 W 96TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1192
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1305 W 96TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1192
Practice Address - Country:US
Practice Address - Phone:317-580-9867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001438A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100216510AMedicaid
IN000000189532OtherBCBS
IN645867OtherACN
IN100216510AMedicaid
INT93066Medicare UPIN