Healthcare Provider Details

I. General information

NPI: 1245214543
Provider Name (Legal Business Name): JERRY M JOHNSON ETAL PTR FOUR SEASONS PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 12/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W WELLESLEY AVE
SPOKANE WA
99205-1274
US

IV. Provider business mailing address

1111 W WELLESLEY AVE
SPOKANE WA
99205-1274
US

V. Phone/Fax

Practice location:
  • Phone: 509-327-1578
  • Fax: 509-327-1596
Mailing address:
  • Phone: 509-327-1578
  • Fax: 509-327-1596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number601871376
License Number StateWA

VIII. Authorized Official

Name: MR. JERRY MICHAEL JOHNSON
Title or Position: ADMINISTRATIVE DIRECTOR
Credential: PT
Phone: 509-327-1578