Basic Information
| Provider Information | |||||||||
| NPI: | 1427053867 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JARROD | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 490 | ||||||||
| Address2: | |||||||||
| City: | LITTLEFIELD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864320490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283475971 | ||||||||
| FaxNumber: | 9283475793 | ||||||||
| Practice Location | |||||||||
| Address1: | I15 EXIT 9 @ THE FIRESTATION | ||||||||
| Address2: | |||||||||
| City: | LITTLEFIELD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864320490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283475971 | ||||||||
| FaxNumber: | 9283475793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4092 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 856940 | 05 | AZ | MEDICAID |