Provider Demographics
NPI:1528374329
Name:JOHNSON, JEREMY (PSY D)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3104 BLUE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35243-2345
Mailing Address - Country:US
Mailing Address - Phone:205-977-3003
Mailing Address - Fax:
Practice Address - Street 1:3104 BLUE LAKE DR
Practice Address - Street 2:
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35243-2345
Practice Address - Country:US
Practice Address - Phone:205-977-3003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1741103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical