Provider Demographics
NPI:1083897011
Name:JOHNSON, JEREMY MICHAEL (LPN)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:MICHAEL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 N LOS ALTOS CT
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-8357
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3401 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-4517
Practice Address - Country:US
Practice Address - Phone:623-691-4085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP031774164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse