Healthcare Provider Details

I. General information

NPI: 1710830005
Provider Name (Legal Business Name): JOHN KENNETH SUMMERVILLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2026
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 SW 6TH ST
GRESHAM OR
97080-9475
US

IV. Provider business mailing address

2700 W POWELL BLVD APT 209
GRESHAM OR
97030-6569
US

V. Phone/Fax

Practice location:
  • Phone: 503-568-6056
  • Fax:
Mailing address:
  • Phone: 503-568-6056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: