Provider Demographics
NPI:1073676474
Name:JOHNSON, JEFFREY JOSEPH (PT CSCS)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JOSEPH
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 59TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-4630
Mailing Address - Country:US
Mailing Address - Phone:941-794-3305
Mailing Address - Fax:941-792-8881
Practice Address - Street 1:1812 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4630
Practice Address - Country:US
Practice Address - Phone:941-794-3305
Practice Address - Fax:941-792-8881
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT13473171W00000X
PA013473225100000X
FL013473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY7004Medicare ID - Type UnspecifiedPHYSICAL THERAPIST