Provider Demographics
NPI:1750421160
Name:JOHNSON, JEREL DEAN (ABOC OPTICIAN)
Entity type:Individual
Prefix:
First Name:JEREL
Middle Name:DEAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:ABOC OPTICIAN
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 127
Mailing Address - Street 2:23 EAST VERMILION AVE
Mailing Address - City:COOK
Mailing Address - State:MN
Mailing Address - Zip Code:55723-0127
Mailing Address - Country:US
Mailing Address - Phone:218-666-2879
Mailing Address - Fax:
Practice Address - Street 1:23 EAST VERMILION AVE
Practice Address - Street 2:
Practice Address - City:COOK
Practice Address - State:MN
Practice Address - Zip Code:55723-0127
Practice Address - Country:US
Practice Address - Phone:218-666-2879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19618156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN66791COOther1ST PLAN BLUE
MN110191OtherUCARE
MN2100594OtherMEDICA
MN66791COOtherBCBS
MN0591300001Medicare ID - Type Unspecified