Active NPI
Jack Claudious Justice III, PA-C
- Physician Assistant
- Johnson City, TN
National Provider Identifier
1871180117
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- 4367
- Practice address
- 2244 Boones Creek Rd
Johnson City, TN 37615-4432 - Phone
- (423) 782-0243
- NPI assigned
- Dec 21, 2020
- 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 |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 4367 | TN | Primary |
Addresses
Primary practice location
2244 Boones Creek Rd
Johnson City, TN 37615-4432
Mailing address
2244 Boones Creek Rd
Johnson City, TN 37615-4432
Phone (423) 782-0243
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: No
- Opted out of Medicare
- Yes, effective Jan 1, 2023 through Jan 1, 2027
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4367 | TN | MD | Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1608508800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1608681600000",
"number": "1871180117",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2244 BOONES CREEK RD",
"city": "JOHNSON CITY",
"state": "TN",
"postal_code": "376154432",
"telephone_number": "423-782-0243"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2244 BOONES CREEK RD",
"city": "JOHNSON CITY",
"state": "TN",
"postal_code": "376154432",
"telephone_number": "423-782-0243"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JUSTICE",
"first_name": "JACK",
"middle_name": "CLAUDIOUS",
"name_prefix": "Mr.",
"name_suffix": "III",
"credential": "PA-C",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2020-12-21",
"last_updated": "2020-12-23",
"certification_date": "2020-12-23",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "TN",
"license": "4367",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Johnson City, TN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 23, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.