Provider Demographics
NPI:1750013199
Name:JOHNSON, DOMINQUE
Entity type:Individual
Prefix:DR
First Name:DOMINQUE
Middle Name:
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 1:8450 GATE PKWY W UNIT 1718
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1054
Mailing Address - Country:US
Mailing Address - Phone:850-339-4493
Mailing Address - Fax:
Practice Address - Street 1:5233 RICKER RD STE 102
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-1439
Practice Address - Country:US
Practice Address - Phone:904-320-0706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH14112111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor