Healthcare Provider Details

I. General information

NPI: 1790505865
Provider Name (Legal Business Name): JOHN LEROY CLEMONS CRM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

389 SW SCALEHOUSE CT
BEND OR
97702-3241
US

IV. Provider business mailing address

389 SW SCALEHOUSE CT
BEND OR
97702-3241
US

V. Phone/Fax

Practice location:
  • Phone: 541-306-4443
  • Fax: 541-550-2011
Mailing address:
  • Phone: 541-306-4443
  • Fax: 541-550-2011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number25-QMHA-R-7845
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number24-CRM-3777
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: