MEDICARE: DR. JEREMY JOHNSON PSY. D.

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	103TC0700X	Clinical Psychologist	1741	AL
2	103TC2200X	Clinical Child & Adolescent Psychologist	1741	AL

General Provider Information

NPI Number	:	1528374329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEREMY JOHNSON PSY. D.

Provider Business Mailing Address
First Line	:	3104 BLUE LAKE DR
Second Line	:
City	:	VESTAVIA
State	:	AL
Zip	:	35243-2345
Country	:	US
Telephone Number	:	205-977-3003
Fax Number	:

Provider Business Practice Location Address
First Line	:	3104 BLUE LAKE DR
Second Line	:
City	:	VESTAVIA
State	:	AL
Zip	:	35243-2345
Country	:	US
Telephone Number	:	205-977-3003
Fax Number	:

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

Provider Enumeration Date	:	08/31/2010
Last Update Date	:	03/14/2012

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