Provider Demographics
NPI:1639401755
Name:JEREMIAH JOHNSON
Entity Type:Organization
Organization Name:JEREMIAH JOHNSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PRACTICAL NURSE
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-429-7880
Mailing Address - Street 1:3035 W WISCONSIN AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-3987
Mailing Address - Country:US
Mailing Address - Phone:414-429-7880
Mailing Address - Fax:
Practice Address - Street 1:3035 W WISCONSIN AVE APT 205
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3987
Practice Address - Country:US
Practice Address - Phone:414-429-7880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-01
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI311777-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty