Provider Demographics
NPI:1669874913
Name:JOHNSON, JEREMIAH (BSN)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13310 E MISSION AVE
Mailing Address - Street 2:APT #114
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-2723
Mailing Address - Country:US
Mailing Address - Phone:509-481-7650
Mailing Address - Fax:
Practice Address - Street 1:850 MAPLE ST.
Practice Address - Street 2:
Practice Address - City:MEDICAL LAKE
Practice Address - State:WA
Practice Address - Zip Code:99022
Practice Address - Country:US
Practice Address - Phone:509-565-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60268562163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse