| Doctor Name: | JEREL DEAN JOHNSON |
| NPI Number: | 1750421160 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | ABOC OPTICIAN |
| License Number: | 19618 |
| Business Practice Address: | 23 East Vermilion Ave Cook, MN - 557230127 |
| Business Phone Number: | 2186662879 |
| Business Fax Number: | |
| Mailing Address: | Po Box 127, 23 East Vermilion Ave COOK |
| State: | MN |
| Postal Code: | 557230127 |
| Phone Number: | 2186662879 |
| Fax Number: | |
| NPI Enumeration Date: | 02/07/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 156FX1800X |
| License Number: | 19618 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Eye and Vision Services Providers |
| Taxonomy Classification: | Technician/Technologist |
| Taxonomy Specialization: | Optician |
| Taxonomy Definition: | |