Healthcare Provider Details

I. General information

NPI: 1891764213
Provider Name (Legal Business Name): JUMAAH INGRAM JOHNSON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 WALNUT ST SUITE 210
PHILADELPHIA PA
19103-5313
US

IV. Provider business mailing address

420 BAINBRIDGE ST
PHILADELPHIA PA
19147-1568
US

V. Phone/Fax

Practice location:
  • Phone: 215-545-8717
  • Fax: 215-545-9355
Mailing address:
  • Phone: 215-629-1270
  • Fax: 215-629-5531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT017980
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: