Provider Demographics
NPI:1174873723
Name:JOHNSON, JACOB DARRELL (DPT)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:DARRELL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 NORTH CENTER STREET
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LONOKE
Mailing Address - State:AR
Mailing Address - Zip Code:72086
Mailing Address - Country:US
Mailing Address - Phone:501-676-5540
Mailing Address - Fax:501-676-6499
Practice Address - Street 1:1515 NORTH CENTER STREET
Practice Address - Street 2:SUITE 5
Practice Address - City:LONOKE
Practice Address - State:AR
Practice Address - Zip Code:72086
Practice Address - Country:US
Practice Address - Phone:501-676-5540
Practice Address - Fax:501-676-6499
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 3506225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR127083742Medicaid
AR127083742Medicaid