Healthcare Provider Details

I. General information

NPI: 1992219521
Provider Name (Legal Business Name): JEPARIS JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2017
Last Update Date: 11/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10411 N COLLEGE AVE
INDIANAPOLIS IN
46280-1436
US

IV. Provider business mailing address

10411 N COLLEGE AVE
INDIANAPOLIS IN
46280-1436
US

V. Phone/Fax

Practice location:
  • Phone: 317-688-7748
  • Fax:
Mailing address:
  • Phone: 317-688-7748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number17-014066-1
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: