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NPI Code Detail

MEDICARE: MR. KENNETH R JOHNSON JR. 101YM0800X.

MEDICARE: MR. KENNETH R JOHNSON JR. 101YM0800X.
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
1101YA0400XAddiction (Substance Use Disorder) CounselorOR

General Provider Information

NPI Number : 1730034364
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. KENNETH R JOHNSON JR. 101YM0800X.
Provider Business Mailing Address
First Line : 605 SE JACK AVE
Second Line :
City : MCMINNVILLE
State : OR
Zip : 97128-5345
Country : US
Telephone Number : 971-237-8337
Fax Number :
Provider Business Practice Location Address
First Line : 182 SW ACADEMY ST
Second Line :
City : DALLAS
State : OR
Zip : 97338-1996
Country : US
Telephone Number : 503-623-9289
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/27/2026
Last Update Date : 02/27/2026

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