Healthcare Provider Details

I. General information

NPI: 1851596126
Provider Name (Legal Business Name): JERRY JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 E SONTERRA BLVD
SAN ANTONIO TX
78258-4089
US

IV. Provider business mailing address

1202 E SONTERRA BLVD
SAN ANTONIO TX
78258-4089
US

V. Phone/Fax

Practice location:
  • Phone: 210-499-6500
  • Fax: 210-499-6574
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: