Healthcare Provider Details

I. General information

NPI: 1144945296
Provider Name (Legal Business Name): DAMION JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 10/11/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 STATE ST STE 101
SALEM OR
97301-4541
US

IV. Provider business mailing address

5852 NE AINSWORTH ST
PORTLAND OR
97218-2354
US

V. Phone/Fax

Practice location:
  • Phone: 503-749-5760
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: