Provider Demographics
NPI:1972669646
Name:JOHNSON, KEITH (PT)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-8050
Mailing Address - Country:US
Mailing Address - Phone:870-680-2626
Mailing Address - Fax:
Practice Address - Street 1:2301 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-8050
Practice Address - Country:US
Practice Address - Phone:870-680-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT 8230225100000X
ARPT1729225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR133568721Medicaid