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General NPI Number Information
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NPI Number | 1669399903
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Entity Type | Individual
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Provider Name | JACOB O JOHNSON
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Gender | Male
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Dates
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Enumeration Date | 06/29/2026
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Last Update Date | 06/29/2026
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Provider Practice Location Address
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Address Line | 1217 NE BURNSIDE RD STE 701
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City | GRESHAM
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State | OR
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Zip | 97030-5770
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Country | US
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Telephone | 503-740-1971
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Fax | 503-771-2436
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Provider Business Mailing Address
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Address Line | 17893 SW NELS DR
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City | SHERWOOD
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State | OR
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Zip | 97140-8079
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Country | US
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Telephone | 503-332-9041
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Fax | 503-771-2436
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | T-25-5918
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License Number State | OR
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