Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2081S0010X | Sports Medicine | 777 | NE |
N | 213ES0000X | Sports Medicine | 777 | NE |
NPI | 1073083457 |
---|---|
Provider Name | Jade Taylir Johnson |
First Address | Wayne, NE 68787-2210 |
Second Address | Wayne, NE 68787-1181 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/11/2018 |
Last Update Date | 28/11/2018 |