Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist | 6301013224 | MI |
NPI | 1417164542 |
---|---|
Provider Name | Dr. Jeremy L Johnson |
First Address | Grand Rapids, MI 49506-4336 |
Second Address | Grand Rapids, MI 49506-4336 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2007 |
Last Update Date | 08/07/2007 |