Provider Demographics
NPI:1194115030
Name:JOHNSTONE, JERRY ROY (LMT)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:ROY
Last Name:JOHNSTONE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1641 E OSBORN RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7146
Mailing Address - Country:US
Mailing Address - Phone:602-265-1774
Mailing Address - Fax:602-265-1738
Practice Address - Street 1:1641 E OSBORN RD
Practice Address - Street 2:SUITE 6
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7146
Practice Address - Country:US
Practice Address - Phone:602-265-1774
Practice Address - Fax:602-265-1738
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-14033225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist