Provider Demographics
NPI:1356447999
Name:JOHNSON, LUCAS JARED (MPT)
Entity Type:Individual
Prefix:MR
First Name:LUCAS
Middle Name:JARED
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17823 COUNTRYSIDE CT
Mailing Address - Street 2:
Mailing Address - City:PRUNEDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93907-8804
Mailing Address - Country:US
Mailing Address - Phone:831-663-8818
Mailing Address - Fax:831-663-5376
Practice Address - Street 1:17823 COUNTRYSIDE CT
Practice Address - Street 2:
Practice Address - City:PRUNEDALE
Practice Address - State:CA
Practice Address - Zip Code:93907-8804
Practice Address - Country:US
Practice Address - Phone:831-663-8818
Practice Address - Fax:831-663-5376
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT30111225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0PT301110Medicare UPIN
CAZZZ02074ZMedicare PIN