Provider Demographics
NPI:1851673008
Name:JOHNSON, JACOB V (DO)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:V
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1359
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82902-1359
Mailing Address - Country:US
Mailing Address - Phone:307-212-7708
Mailing Address - Fax:307-352-8148
Practice Address - Street 1:3000 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4202
Practice Address - Country:US
Practice Address - Phone:307-212-7708
Practice Address - Fax:307-352-8148
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9086A207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine