Healthcare Provider Details

I. General information

NPI: 1932091626
Provider Name (Legal Business Name): JEROME NATHANIEL JOHNSON L.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3331 POWER INN RD # 140
SACRAMENTO CA
95826-3889
US

IV. Provider business mailing address

9301 JUNIPER LAKE ALY
SACRAMENTO CA
95829-8746
US

V. Phone/Fax

Practice location:
  • Phone: 916-875-1183
  • Fax: 916-875-1190
Mailing address:
  • Phone: 909-912-4631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number42083
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: