Provider Demographics
NPI:1902428238
Name:JOHNSON, JARED JOSHUA
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:JOSHUA
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2254 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-8400
Mailing Address - Country:US
Mailing Address - Phone:909-568-8777
Mailing Address - Fax:
Practice Address - Street 1:10601 PARAMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3303
Practice Address - Country:US
Practice Address - Phone:562-923-7257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1059191223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program