Provider Demographics
NPI:1902479926
Name:JOHNSON, JEFF
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:
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 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:17800 KEDZIE AVE STE AIP
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2029
Practice Address - Country:US
Practice Address - Phone:708-213-3230
Practice Address - Fax:708-213-0101
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041383616163WC0200X
IL209023852363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine