Provider Demographics
NPI:1679464119
Name:JOHNSON, JAYDEN JACK
Entity type:Individual
Prefix:
First Name:JAYDEN
Middle Name:JACK
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 1:527 5TH AVE S APT F6
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-3340
Mailing Address - Country:US
Mailing Address - Phone:605-924-0521
Mailing Address - Fax:
Practice Address - Street 1:527 5TH AVE S APT F6
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-3340
Practice Address - Country:US
Practice Address - Phone:605-924-0521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-12
Last Update Date:2025-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
E3904089171000000X, 146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic