Basic Information
| Provider Information | |||||||||
| NPI: | 1982688529 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 W WELLESLEY AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992051274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093271578 | ||||||||
| FaxNumber: | 5093271596 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 W WELLESLEY AVE | ||||||||
| Address2: | FOUR SEASONS PHYSICAL THERAPY | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992051274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093271578 | ||||||||
| FaxNumber: | 5093271596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 09/27/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00000931 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8345829 | 05 | WA | MEDICAID | 7025307 | 05 | WA | MEDICAID |