Provider Demographics
NPI:1992219521
Name:JOHNSON, JEPARIS
Entity Type:Individual
Prefix:
First Name:JEPARIS
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10411 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46280-1436
Mailing Address - Country:US
Mailing Address - Phone:317-688-7748
Mailing Address - Fax:
Practice Address - Street 1:10411 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46280-1436
Practice Address - Country:US
Practice Address - Phone:317-688-7748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17-014066-13747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300008106Medicaid