Active NPI
Jerald Johnson
- Medical Laboratory Technician
- Fargo, ND
National Provider Identifier
1669856225
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Medical Laboratory Technician
- License
- 04200308
- Practice address
- 1618 E Gateway Cir S
Apt 301
Fargo, ND 58103-3657 - Phone
- (612) 384-0964
- NPI assigned
- Jul 14, 2015
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Medical Laboratory Technician | 246RM2200X | 04200308 | MN | Primary |
Addresses
Primary practice location
1618 E Gateway Cir S
Apt 301
Fargo, ND 58103-3657
Mailing address
1618 E Gateway Cir S
Apt 301
Fargo, ND 58103-3657
Phone (612) 384-0964
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 04200308 | MN | MD | Medical Laboratory Technician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1436832000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1436832000000",
"number": "1669856225",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1618 E GATEWAY CIR S",
"address_2": "APT 301",
"city": "FARGO",
"state": "ND",
"postal_code": "581033657",
"telephone_number": "612-384-0964"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1618 E GATEWAY CIR S",
"address_2": "APT 301",
"city": "FARGO",
"state": "ND",
"postal_code": "581033657",
"telephone_number": "612-384-0964"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JOHNSON",
"first_name": "JERALD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2015-07-14",
"last_updated": "2015-07-14",
"status": "A"
},
"taxonomies": [
{
"code": "246RM2200X",
"taxonomy_group": "",
"desc": "Technician, Pathology, Medical Laboratory",
"state": "MN",
"license": "04200308",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fargo, ND
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 14, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.