Provider Demographics
NPI:1063886935
Name:JOHNSON, JEFFREY (PA-C)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-304-8476
Mailing Address - Fax:425-304-8477
Practice Address - Street 1:7425 JANES AVE
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-2356
Practice Address - Country:US
Practice Address - Phone:708-550-7005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-16
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005650363AM0700X
WAPA61271444363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical