Provider Demographics
NPI:1578301461
Name:JOHNSON, JERRICK (RN)
Entity type:Individual
Prefix:
First Name:JERRICK
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 COMMERCIAL PARK CT APT 145
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-6992
Mailing Address - Country:US
Mailing Address - Phone:501-416-8867
Mailing Address - Fax:
Practice Address - Street 1:100 COMMERCIAL PARK CT APT 145
Practice Address - Street 2:
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113-6992
Practice Address - Country:US
Practice Address - Phone:501-416-8867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR11221112610146D00000X
AR218478163WR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0400XNursing Service ProvidersRegistered NurseRehabilitation
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant