Provider Demographics
NPI:1699922831
Name:JOHNSON, JEREMIAH B (DC)
Entity type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 W MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KS
Mailing Address - Zip Code:67301-8485
Mailing Address - Country:US
Mailing Address - Phone:620-331-5300
Mailing Address - Fax:
Practice Address - Street 1:1802 W MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:INDEPENDENCE
Practice Address - State:KS
Practice Address - Zip Code:67301-8485
Practice Address - Country:US
Practice Address - Phone:620-331-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-02193111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor