Provider Demographics
NPI:1972731305
Name:JOHNSON, JEREMY ALLEN (DPT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:ALLEN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX C8502
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-8599
Mailing Address - Country:US
Mailing Address - Phone:660-785-1834
Mailing Address - Fax:660-785-1825
Practice Address - Street 1:2814 S BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4640
Practice Address - Country:US
Practice Address - Phone:660-785-1834
Practice Address - Fax:660-785-1825
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009014098225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1814014Medicare PIN
MOMA1811014Medicare PIN