Healthcare Provider Details

I. General information

NPI: 1699744102
Provider Name (Legal Business Name): JASON BRADLEY JOHNSON SF-IDC/CIHM
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 844 BOX 63
FPO AE
09844
US

IV. Provider business mailing address

PSC 844 BOX 63
FPO AE
09844
US

V. Phone/Fax

Practice location:
  • Phone: 00302492029290
  • Fax:
Mailing address:
  • Phone: 00302492029290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: