Provider Demographics
NPI:1942745369
Name:JOHNSON, JEREMY (PT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 SCHULER BRANCH
Mailing Address - Street 2:
Mailing Address - City:DEANE
Mailing Address - State:KY
Mailing Address - Zip Code:41812
Mailing Address - Country:US
Mailing Address - Phone:606-377-3400
Mailing Address - Fax:606-377-3489
Practice Address - Street 1:9879 KY ROUTE 122
Practice Address - Street 2:
Practice Address - City:MC DOWELL
Practice Address - State:KY
Practice Address - Zip Code:41647-6026
Practice Address - Country:US
Practice Address - Phone:606-377-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005734225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist