Provider Demographics
NPI:1114728771
Name:JOHNSON, JAMAR LYDELL
Entity type:Individual
Prefix:
First Name:JAMAR
Middle Name:LYDELL
Last Name:JOHNSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5307 TUCKER ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68152-1831
Mailing Address - Country:US
Mailing Address - Phone:402-880-0846
Mailing Address - Fax:402-880-0846
Practice Address - Street 1:5307 TUCKER ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68152-1831
Practice Address - Country:US
Practice Address - Phone:402-880-0846
Practice Address - Fax:402-880-0846
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor