Provider Demographics
NPI:1871130112
Name:JOHNSON, JACKIE GLEN
Entity type:Individual
Prefix:MR
First Name:JACKIE
Middle Name:GLEN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 ASHLAWN DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-5612
Mailing Address - Country:US
Mailing Address - Phone:817-609-5474
Mailing Address - Fax:469-672-6069
Practice Address - Street 1:434 ASHLAWN DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-5612
Practice Address - Country:US
Practice Address - Phone:817-609-5474
Practice Address - Fax:469-672-6069
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management