Provider Demographics
NPI:1295784510
Name:JOHNSON, JAN RONALD (PT)
Entity type:Individual
Prefix:MR
First Name:JAN
Middle Name:RONALD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 TAHOE KEYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-3314
Mailing Address - Country:US
Mailing Address - Phone:530-542-5750
Mailing Address - Fax:
Practice Address - Street 1:585 TAHOE KEYS BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-3314
Practice Address - Country:US
Practice Address - Phone:530-542-5750
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6891225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT68910Medicare ID - Type UnspecifiedPHYSICAL THERAPIST