Provider Demographics
NPI:1982120895
Name:JOHNSON, JACOB LYNN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5021 TAFT BLVD APT 3302
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-5391
Mailing Address - Country:US
Mailing Address - Phone:701-339-1678
Mailing Address - Fax:
Practice Address - Street 1:BLDG 1200, 149G W HART ST
Practice Address - Street 2:
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311-7631
Practice Address - Country:US
Practice Address - Phone:940-676-4412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2023-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017020610122300000X
TX348581223G0001X, 171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice