Healthcare Provider Details

I. General information

NPI: 1366966616
Provider Name (Legal Business Name): KATHLEEN M JOHNSON MSN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHLEEN M JOHNSON PMHNP-BC

II. Dates (important events)

Enumeration Date: 07/28/2017
Last Update Date: 07/26/2021
Certification Date: 07/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 E BROADWAY STE 730
EUGENE OR
97401-3160
US

IV. Provider business mailing address

132 E BROADWAY STE 730
EUGENE OR
97401-3160
US

V. Phone/Fax

Practice location:
  • Phone: 303-903-6681
  • Fax:
Mailing address:
  • Phone: 541-357-9433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number202106762NP-PP
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: