Provider Demographics
NPI:1184110850
Name:JOHNSON, JAMIE L
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 ELBA HWY
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:AL
Mailing Address - Zip Code:36079-6020
Mailing Address - Country:US
Mailing Address - Phone:334-670-6726
Mailing Address - Fax:334-670-6731
Practice Address - Street 1:100 W LAKE PROFESSIONAL PARK STE 3
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:AL
Practice Address - Zip Code:36340-1200
Practice Address - Country:US
Practice Address - Phone:334-684-8905
Practice Address - Fax:334-684-8908
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-118761207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL280895Medicaid