Healthcare Provider Details

I. General information

NPI: 1568739100
Provider Name (Legal Business Name): JASON RUSSELL JOHNSON ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 WOODLAND SQUARE LOOP SE # B8
LACEY WA
98503-1000
US

IV. Provider business mailing address

677 WOODLAND SQUARE LOOP SE # B8
LACEY WA
98503-1000
US

V. Phone/Fax

Practice location:
  • Phone: 360-623-4181
  • Fax: 360-539-0972
Mailing address:
  • Phone: 360-623-4181
  • Fax: 360-539-0972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP60642223
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: