Healthcare Provider Details

I. General information

NPI: 1255265336
Provider Name (Legal Business Name): JENNA GRACE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 S HOLLY ST
MEDFORD OR
97501-3113
US

IV. Provider business mailing address

140 S HOLLY ST
MEDFORD OR
97501-3113
US

V. Phone/Fax

Practice location:
  • Phone: 541-774-8200
  • Fax:
Mailing address:
  • Phone: 541-774-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number26-QMHA-R-8705
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: