Provider Demographics
NPI:1922997907
Name:JOHNSON, JEREMIAH (LVN)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17199 VITA WAY
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-7315
Mailing Address - Country:US
Mailing Address - Phone:951-489-2667
Mailing Address - Fax:
Practice Address - Street 1:17199 VITA WAY
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-7315
Practice Address - Country:US
Practice Address - Phone:951-489-2667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-02
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA215300164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse