Provider Demographics
NPI:1114000130
Name:JOHNSON, JEDIDIAH E (HS1, IDC)
Entity Type:Individual
Prefix:
First Name:JEDIDIAH
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:HS1, IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4688 HOMER SPIT RD
Mailing Address - Street 2:USCGC HICKORY
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603
Mailing Address - Country:US
Mailing Address - Phone:360-567-8238
Mailing Address - Fax:
Practice Address - Street 1:4688 HOMER SPIT RD
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-8001
Practice Address - Country:US
Practice Address - Phone:360-567-8238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other