Provider Demographics
NPI:1730699695
Name:JOHNSON, JACK N (ND)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:N
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:ND
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:N
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ND
Mailing Address - Street 1:5603 38TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-8218
Mailing Address - Country:US
Mailing Address - Phone:253-857-5544
Mailing Address - Fax:253-857-9088
Practice Address - Street 1:5603 38TH AVE NW
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-8218
Practice Address - Country:US
Practice Address - Phone:253-857-5544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT60799742175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath