Healthcare Provider Details

I. General information

NPI: 1982343612
Provider Name (Legal Business Name): MITCHELL JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 A1A N STE 307
PONTE VEDRA FL
32082-3219
US

IV. Provider business mailing address

3901 UNIVERSITY BLVD S
JACKSONVILLE FL
32216-4312
US

V. Phone/Fax

Practice location:
  • Phone: 904-543-4021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT38790
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: