Healthcare Provider Details

I. General information

NPI: 1952754442
Provider Name (Legal Business Name): NATHAN PATRICK JOHNSON PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4035 12TH ST CUTOFF SE STE 120
SALEM OR
97302
US

IV. Provider business mailing address

PO BOX 12926
SALEM OR
97309-0926
US

V. Phone/Fax

Practice location:
  • Phone: 971-304-9306
  • Fax: 503-926-6624
Mailing address:
  • Phone: 971-304-9306
  • Fax: 503-926-6624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number209338
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number201701389RN
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number201701390NPPP
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0000022011
License Number StateTN
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201701390NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: