Provider Demographics
NPI:1699720185
Name:JOHNSON, JEFFERY JAMES (CRNA)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:JAMES
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2173 DECKER RD APT 48
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-2509
Mailing Address - Country:US
Mailing Address - Phone:248-701-7782
Mailing Address - Fax:
Practice Address - Street 1:23901 LAHSER RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-6035
Practice Address - Country:US
Practice Address - Phone:248-357-3360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704215208367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104692611Medicaid
MIJJ215208OtherBLUE CROSS OF MI