Provider Demographics
NPI:1720561863
Name:JOHNSON, JEREMY (CTRS)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3414 CURTIS DR
Mailing Address - Street 2:
Mailing Address - City:SUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20746-4935
Mailing Address - Country:US
Mailing Address - Phone:202-271-2395
Mailing Address - Fax:
Practice Address - Street 1:3414 CURTIS DR
Practice Address - Street 2:
Practice Address - City:SUITLAND
Practice Address - State:MD
Practice Address - Zip Code:20746-4935
Practice Address - Country:US
Practice Address - Phone:202-271-2395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
59263225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1851874051Medicaid
MD83-1623156OtherMARYLAND