Provider Demographics
NPI:1144415233
Name:JOHNSON, JEREMY THOMAS (CRNA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:THOMAS
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3330
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3330
Mailing Address - Country:US
Mailing Address - Phone:888-333-1095
Mailing Address - Fax:770-701-6674
Practice Address - Street 1:1253 NW CANAL BLVD
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1334
Practice Address - Country:US
Practice Address - Phone:541-548-8131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC196302367500000X
OR201393463CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered