Provider Demographics
NPI:1699584755
Name:JOHNSON, JACOB REECE (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:REECE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3839 W CONGRESS ST STE B
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-6000
Mailing Address - Country:US
Mailing Address - Phone:870-826-1511
Mailing Address - Fax:
Practice Address - Street 1:3839 W CONGRESS ST STE B
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-6000
Practice Address - Country:US
Practice Address - Phone:870-826-1511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-03
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA76361223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty