Provider Demographics
NPI:1962638999
Name:JOHNSON, JACK FRANK III (APRN)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:FRANK
Last Name:JOHNSON
Suffix:III
Gender:M
Credentials:APRN
Other - Prefix:MR
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:724 ARDEN LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-2996
Mailing Address - Country:US
Mailing Address - Phone:803-980-7337
Mailing Address - Fax:803-980-2229
Practice Address - Street 1:724 ARDEN LN
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2996
Practice Address - Country:US
Practice Address - Phone:803-980-7337
Practice Address - Fax:803-980-2229
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3360364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3360OtherSOUTH CAROLINA STATE LICENSE
SC54-03360OtherSOUTH CAROLINA CONTROLLED SUBSTANCES CERTIFICATE OF REGISTRATION