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NPI Code Detail

MEDICARE: JEREMIAH JOHNSON

MEDICARE: JEREMIAH JOHNSON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker9262-123WI

General Provider Information

NPI Number : 1669027066
Entity Type Code : Individual
Provider Name (Legal Business Name) : JEREMIAH JOHNSON
Provider Business Mailing Address
First Line : 5215 N IRONWOOD RD STE 202
Second Line :
City : GLENDALE
State : WI
Zip : 53217-4908
Country : US
Telephone Number : 715-903-6444
Fax Number :
Provider Business Practice Location Address
First Line : 5215 N IRONWOOD RD STE 202
Second Line :
City : GLENDALE
State : WI
Zip : 53217-4908
Country : US
Telephone Number : 715-903-6444
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/03/2019
Last Update Date : 05/06/2023

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