Provider Demographics
NPI:1609260579
Name:JOHNSON, JASON ARTHUR (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ARTHUR
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 GROSS POINT RD
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1214
Mailing Address - Country:US
Mailing Address - Phone:847-677-9600
Mailing Address - Fax:847-933-6036
Practice Address - Street 1:9600 GROSS POINT RD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1214
Practice Address - Country:US
Practice Address - Phone:847-677-9600
Practice Address - Fax:847-933-6036
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085008816363A00000X
MN11997363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400259412Medicare UPIN