Provider Demographics
NPI:1598368557
Name:JOHNSON, JACOB (MT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6555 E COUNTY ROAD 700 N
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-9024
Mailing Address - Country:US
Mailing Address - Phone:925-549-0467
Mailing Address - Fax:
Practice Address - Street 1:6319 E US HIGHWAY
Practice Address - Street 2:SUITE 9
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-4612
Practice Address - Country:US
Practice Address - Phone:317-707-7151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT22007253225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist