Provider Demographics
NPI:1255392825
Name:JOHNSON, SCOTT ALLEN (DC)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:ALLEN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
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 5801
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-5801
Mailing Address - Country:US
Mailing Address - Phone:228-826-2724
Mailing Address - Fax:228-826-1669
Practice Address - Street 1:5600 C L DEES DR
Practice Address - Street 2:
Practice Address - City:VANCLEAVE
Practice Address - State:MS
Practice Address - Zip Code:39565-8346
Practice Address - Country:US
Practice Address - Phone:228-826-2724
Practice Address - Fax:228-826-1669
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0876111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0115369Medicaid
MSCP43105OtherCOMPLETE HEALTH
MS5219536OtherAETNA NETWORK
MS869651OtherFIRST HEALTH NETWORK
LA3203AOtherBC/BS OF LA
AL730-69128OtherBC/BS OF AL
AL730-69128OtherBC/BS OF AL
MS0115369Medicaid