Provider Demographics
NPI:1588273999
Name:JOHNSON, JACOB (SOIDC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 SALVO CT
Mailing Address - Street 2:
Mailing Address - City:HOLLY RIDGE
Mailing Address - State:NC
Mailing Address - Zip Code:28445-8609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:413 SALVO CT
Practice Address - Street 2:
Practice Address - City:HOLLY RIDGE
Practice Address - State:NC
Practice Address - Zip Code:28445-8609
Practice Address - Country:US
Practice Address - Phone:573-201-6504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman