MEDICARE: JEREMY 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
1	171400000X	Health & Wellness Coach

General Provider Information

NPI Number	:	1790627842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY JOHNSON

Provider Business Mailing Address
First Line	:	9101 NW 87TH ST
Second Line	:
City	:	YUKON
State	:	OK
Zip	:	73099-0002
Country	:	US
Telephone Number	:	405-412-5814
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 NW EXPRESSWAY STE 106
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-1803
Country	:	US
Telephone Number	:	405-412-5814
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2026
Last Update Date	:	04/07/2026

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