Healthcare Provider Details

I. General information

NPI: 1407141948
Provider Name (Legal Business Name): JEREMY DAVID JOHNSON M.D., MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 7TH AVE
SEATTLE WA
98104-1132
US

IV. Provider business mailing address

7600 EVERGREEN WAY
EVERETT WA
98203-6421
US

V. Phone/Fax

Practice location:
  • Phone: 206-860-5584
  • Fax: 206-720-7428
Mailing address:
  • Phone: 206-860-5414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD60358064
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number62508-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: