Basic Information
| Provider Information | |||||||||
| NPI: | 1942745369 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JEREMY | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 169 SCHULER BRANCH | ||||||||
| Address2: | |||||||||
| City: | DEANE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063773400 | ||||||||
| FaxNumber: | 6063773489 | ||||||||
| Practice Location | |||||||||
| Address1: | 9879 KY ROUTE 122 | ||||||||
| Address2: | |||||||||
| City: | MC DOWELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 416476026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063773400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2016 | ||||||||
| LastUpdateDate: | 12/20/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 005734 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.