Individual
MR. JACKIE RAY JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
8200 WALNUT HILL LN, DALLAS, TX 75231-4426
(214) 345-7175
Mailing address
3008 SHILLING RD, TEXARKANA, TX 75503-5423
(903) 792-2173
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
510698
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002509002
—
TX
01
—
89723U
BCBS
TX
Enumeration date
08/05/2006
Last updated
11/18/2009
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