Provider Demographics
NPI:1679707541
Name:JOHNSON, JACKIE H JR (MD)
Entity type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:H
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6479
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31095
Mailing Address - Country:US
Mailing Address - Phone:478-923-5872
Mailing Address - Fax:478-929-6266
Practice Address - Street 1:216 CORDER RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088
Practice Address - Country:US
Practice Address - Phone:478-923-5872
Practice Address - Fax:478-929-6266
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114525207W00000X
VA0116022302390200000X
390200000X
GA068744207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003134708AMedicaid