Provider Demographics
NPI:1558386979
Name:JOHNSON, JEREMIAH EDWIN (RD MPH)
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:EDWIN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 W CASABLANCA AVE
Mailing Address - Street 2:27 SOMDG/SGPM
Mailing Address - City:CANNON AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88103-5009
Mailing Address - Country:US
Mailing Address - Phone:575-784-2843
Mailing Address - Fax:
Practice Address - Street 1:208 W CASABLANCA AVE
Practice Address - Street 2:27 SOMDG/SGPM
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88103-5009
Practice Address - Country:US
Practice Address - Phone:575-784-2843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered