Provider Demographics
NPI:1720597065
Name:JASON DANIEL JOHNSON, PLLC
Entity type:Organization
Organization Name:JASON DANIEL JOHNSON, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-610-2999
Mailing Address - Street 1:15396 N 83RD AVE STE B100
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5626
Mailing Address - Country:US
Mailing Address - Phone:602-610-2999
Mailing Address - Fax:623-321-7821
Practice Address - Street 1:15396 N 83RD AVE STE B100
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5626
Practice Address - Country:US
Practice Address - Phone:602-610-2999
Practice Address - Fax:623-321-7821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-28
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0069292086S0122X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ033104Medicaid