Provider Demographics
NPI:1801274550
Name:JOHNSON, JEREMY TATE (ATC)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:TATE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1637 PERRYVILLE RD.
Mailing Address - Street 2:BOYLE COUNTY HIGH SCHOOL
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422
Mailing Address - Country:US
Mailing Address - Phone:859-236-5047
Mailing Address - Fax:859-236-6826
Practice Address - Street 1:1637 PERRYVILLE RD.
Practice Address - Street 2:BOYLE COUNTY HIGH SCHOOL
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422
Practice Address - Country:US
Practice Address - Phone:859-236-5047
Practice Address - Fax:859-236-6826
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT9072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer