Provider Demographics
NPI:1104581263
Name:JOHNSON, JIMMY T
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:T
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 1:750 BRIDGES AVE E STE A
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-2343
Mailing Address - Country:US
Mailing Address - Phone:870-215-8083
Mailing Address - Fax:
Practice Address - Street 1:1501 DAWSON RD
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-2088
Practice Address - Country:US
Practice Address - Phone:870-630-2328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator