Provider Demographics
NPI:1417820796
Name:JOHNSON, JASON L
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1157 WALDEN CT
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-8827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:526 XENIA AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45410-1824
Practice Address - Country:US
Practice Address - Phone:937-949-1524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-24
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty