Provider Demographics
NPI:1861372096
Name:JOHNSON, JERROLD
Entity type:Individual
Prefix:
First Name:JERROLD
Middle Name:
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 1:6679 BALSAM DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44146-4804
Mailing Address - Country:US
Mailing Address - Phone:407-450-4549
Mailing Address - Fax:
Practice Address - Street 1:6679 BALSAM DR
Practice Address - Street 2:
Practice Address - City:BEDFORD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44146-4804
Practice Address - Country:US
Practice Address - Phone:407-450-4549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172A00000X, 374U00000X, 171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Multi-Specialty
No172A00000XOther Service ProvidersDriverGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty