Provider Demographics
NPI:1114732765
Name:JOHNSON, JONATHAN JOHN
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:JOHN
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 1:129 MEDICINE HORSE DR.
Mailing Address - Street 2:
Mailing Address - City:TO'HAJIILEE
Mailing Address - State:NM
Mailing Address - Zip Code:87026
Mailing Address - Country:US
Mailing Address - Phone:505-908-2307
Mailing Address - Fax:
Practice Address - Street 1:129 MEDICINE HORSE DR.
Practice Address - Street 2:
Practice Address - City:TO'HAJIILEE
Practice Address - State:NM
Practice Address - Zip Code:87026
Practice Address - Country:US
Practice Address - Phone:505-908-2307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMG-1685172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty