Provider Demographics
NPI:1285243493
Name:JOHNSON, JEREMY (CSA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 WINDING WAY DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-5201
Mailing Address - Country:US
Mailing Address - Phone:210-623-0293
Mailing Address - Fax:
Practice Address - Street 1:1016 WINDING WAY DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-5201
Practice Address - Country:US
Practice Address - Phone:210-623-0293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant