Provider Demographics
NPI:1104434604
Name:JOHNSTON, JARED
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:JOHNSTON
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 1:502 W SAINT LOUIS ST
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-1968
Mailing Address - Country:US
Mailing Address - Phone:618-932-8902
Mailing Address - Fax:
Practice Address - Street 1:502 W SAINT LOUIS ST
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896-1968
Practice Address - Country:US
Practice Address - Phone:618-932-8902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.024174225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist