Healthcare Provider Details

I. General information

NPI: 1538623087
Provider Name (Legal Business Name): JESSE JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2019
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 SW GRIFFITH DR STE 201
BEAVERTON OR
97005-2988
US

IV. Provider business mailing address

5050 SW GRIFFITH DR STE 201
BEAVERTON OR
97005-2988
US

V. Phone/Fax

Practice location:
  • Phone: 541-900-4285
  • Fax:
Mailing address:
  • Phone: 541-900-4285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL18502
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: