Provider Demographics
NPI:1700523834
Name:JOHNSON, DASJARAE BRIOR
Entity Type:Individual
Prefix:
First Name:DASJARAE
Middle Name:BRIOR
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
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 1252
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42302-1252
Mailing Address - Country:US
Mailing Address - Phone:270-370-7815
Mailing Address - Fax:
Practice Address - Street 1:126 W 20TH ST STE A
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3704
Practice Address - Country:US
Practice Address - Phone:270-370-7815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYJ11173829172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver