Healthcare Provider Details

I. General information

NPI: 1669399903
Provider Name (Legal Business Name): JACOB O JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 NE BURNSIDE RD STE 701
GRESHAM OR
97030-5770
US

IV. Provider business mailing address

17893 SW NELS DR
SHERWOOD OR
97140-8079
US

V. Phone/Fax

Practice location:
  • Phone: 503-740-1971
  • Fax: 503-771-2436
Mailing address:
  • Phone: 503-332-9041
  • Fax: 503-771-2436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-25-5918
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: