Provider Demographics
NPI:1730260829
Name:JOHNSON, JERRY LEE (DC)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
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 1:11914 N PENNSYLVANIA AVE STE B6
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-7831
Mailing Address - Country:US
Mailing Address - Phone:405-752-8819
Mailing Address - Fax:405-751-1238
Practice Address - Street 1:11914 N PENNSYLVANIA AVE STE B3
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-7831
Practice Address - Country:US
Practice Address - Phone:405-752-8819
Practice Address - Fax:405-751-1238
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2626111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor