Healthcare Provider Details

I. General information

NPI: 1861372096
Provider Name (Legal Business Name): JERROLD JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 09/08/2025
Certification Date: 09/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6679 BALSAM DR
BEDFORD HEIGHTS OH
44146-4804
US

IV. Provider business mailing address

6679 BALSAM DR
BEDFORD HEIGHTS OH
44146-4804
US

V. Phone/Fax

Practice location:
  • Phone: 407-450-4549
  • Fax:
Mailing address:
  • Phone: 407-450-4549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: