MEDICARE: MS. JUMAAH INGRAM JOHNSON DPT

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	174400000X	Specialist	PT017980	PA

General Provider Information

NPI Number	:	1891764213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JUMAAH INGRAM JOHNSON DPT

Provider Business Mailing Address
First Line	:	420 BAINBRIDGE ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19147-1568
Country	:	US
Telephone Number	:	215-629-1270
Fax Number	:	215-629-5531

Provider Business Practice Location Address
First Line	:	1616 WALNUT ST
Second Line	:	SUITE 210
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-5313
Country	:	US
Telephone Number	:	215-545-8717
Fax Number	:	215-545-9355

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

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	07/08/2007

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