Provider Demographics
NPI:1407498074
Name:JOHNSTON, JACOB BENJAMIN
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:BENJAMIN
Last Name:JOHNSTON
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 1:1525 PLAZA ST NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-4614
Mailing Address - Country:US
Mailing Address - Phone:503-877-8567
Mailing Address - Fax:
Practice Address - Street 1:1233 EDGEWATER ST NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-4049
Practice Address - Country:US
Practice Address - Phone:503-378-7526
Practice Address - Fax:503-480-1611
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747A0650X
ORTHW000002220172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider