MEDICARE: JOHNATHAN SAMUEL DETWILER LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LH61055500	WA
2	101YM0800X	Mental Health Counselor	39003508A	IN
3	101YM0800X	Mental Health Counselor	C5666	OR

General Provider Information

NPI Number	:	1558829457
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNATHAN SAMUEL DETWILER LMHC

Provider Business Mailing Address
First Line	:	3124 NE 162ND AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97230-5524
Country	:	US
Telephone Number	:	260-348-9872
Fax Number	:

Provider Business Practice Location Address
First Line	:	816 NE 87TH AVE
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98664-1991
Country	:	US
Telephone Number	:	360-566-4432
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2019
Last Update Date	:	09/23/2025

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