Individual
JEREL DEAN JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
ABOC OPTICIAN
Contact information
Practice address
23 EAST VERMILION AVE, COOK, MN 55723-0127
(218) 666-2879
Mailing address
PO BOX 127, 23 EAST VERMILION AVE, COOK, MN 55723-0127
(218) 666-2879
Taxonomy
Speciality
Code
Description
License number
State
156FX1800X
Optician
Primary
19618
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
110191
UCARE
MN
01
—
2100594
MEDICA
MN
01
—
66791CO
1ST PLAN BLUE
MN
Enumeration date
02/07/2007
Last updated
07/08/2007
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