Provider Demographics
NPI:1417727819
Name:JOHNSON, JON RAY (MA)
Entity Type:Individual
Prefix:MR
First Name:JON RAY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 FIREFIGHTERS MEMORIAL DR # 291
Mailing Address - Street 2:
Mailing Address - City:FORT MONTGOMERY
Mailing Address - State:NY
Mailing Address - Zip Code:10922-9800
Mailing Address - Country:US
Mailing Address - Phone:347-265-0199
Mailing Address - Fax:
Practice Address - Street 1:1400 OLD COUNTRY RD STE C103N
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5156
Practice Address - Country:US
Practice Address - Phone:516-806-6969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY1654421221174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist