Healthcare Provider Details

I. General information

NPI: 1770745457
Provider Name (Legal Business Name): JACKIE EUGENE JOHNSON SR. CADC II/QMHP-C, CSWA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JACK EUGENE JOHNSON CADC II/QMHP-R

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 NW DIVISION ST
GRESHAM OR
97030-5523
US

IV. Provider business mailing address

1776 SW MADISON ST
PORTLAND OR
97205-1715
US

V. Phone/Fax

Practice location:
  • Phone: 503-231-2641
  • Fax: 503-231-1654
Mailing address:
  • Phone: 503-224-1044
  • Fax: 503-621-2235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17-CRM-078
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number24-QMHPC-001514
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberA11750
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number00-11-45
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier500800849
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier500801135
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: