MEDICARE: JESSE JOHNSON M.A.

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1043657687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE JOHNSON M.A.

Provider Business Mailing Address
First Line	:	443 NE KNOTT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-3108
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	443 NE KNOTT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-3108
Country	:	US
Telephone Number	:	503-504-0941
Fax Number	:

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

Provider Enumeration Date	:	05/22/2013
Last Update Date	:	05/22/2013

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