Provider Demographics
NPI:1982688529
Name:JOHNSON, JERRY MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:MICHAEL
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 1:1111 W WELLESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-1274
Mailing Address - Country:US
Mailing Address - Phone:509-327-1578
Mailing Address - Fax:509-327-1596
Practice Address - Street 1:1111 W WELLESLEY AVE
Practice Address - Street 2:FOUR SEASONS PHYSICAL THERAPY
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-1274
Practice Address - Country:US
Practice Address - Phone:509-327-1578
Practice Address - Fax:509-327-1596
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00000931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8345829Medicaid
WA7025307Medicaid
AB15993Medicare ID - Type Unspecified