MEDICARE: MR. LUCAS JARED JOHNSON M.P.T

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT30111	CA

General Provider Information

NPI Number	:	1356447999
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LUCAS JARED JOHNSON M.P.T

Provider Business Mailing Address
First Line	:	17823 COUNTRYSIDE CT
Second Line	:
City	:	PRUNEDALE
State	:	CA
Zip	:	93907-8804
Country	:	US
Telephone Number	:	831-663-8818
Fax Number	:	831-663-5376

Provider Business Practice Location Address
First Line	:	17823 COUNTRYSIDE CT
Second Line	:
City	:	PRUNEDALE
State	:	CA
Zip	:	93907-8804
Country	:	US
Telephone Number	:	831-663-8818
Fax Number	:	831-663-5376

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	11/06/2007

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