Provider Demographics
NPI:1386230571
Name:JOHNSON, JEFF
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2729 SE YAMHILL ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2983
Mailing Address - Country:US
Mailing Address - Phone:541-350-4107
Mailing Address - Fax:
Practice Address - Street 1:6410 NE HALSEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-4742
Practice Address - Country:US
Practice Address - Phone:503-215-4663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-12
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical