Provider Demographics
NPI:1699744102
Name:JOHNSON, JASON BRADLEY (SF-IDC/CIHM)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:BRADLEY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:SF-IDC/CIHM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 844 BOX 63
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09844
Mailing Address - Country:US
Mailing Address - Phone:0030249-202-9290
Mailing Address - Fax:
Practice Address - Street 1:PSC 844 BOX 63
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09844
Practice Address - Country:US
Practice Address - Phone:0030249-202-9290
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman