Healthcare Provider Details

I. General information

NPI: 1306384524
Provider Name (Legal Business Name): JEREMY JOHNSON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653 GOLDEN TRL
CAVE CITY AR
72521-9432
US

IV. Provider business mailing address

653 GOLDEN TRL
CAVE CITY AR
72521-9432
US

V. Phone/Fax

Practice location:
  • Phone: 870-219-6598
  • Fax:
Mailing address:
  • Phone: 870-219-6598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 2626
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: