Provider Demographics
NPI:1679760219
Name:JOHNSON, JAY W (DC)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3906
Mailing Address - Country:US
Mailing Address - Phone:218-847-2809
Mailing Address - Fax:
Practice Address - Street 1:1208 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3906
Practice Address - Country:US
Practice Address - Phone:218-847-2809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2718111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350002679Medicare PIN