Provider Demographics
NPI:1497831713
Name:JOHNSON, JAMES (JIM) CHARLES (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES (JIM)
Middle Name:CHARLES
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:JIM
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:516 SE 71ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-2132
Mailing Address - Country:US
Mailing Address - Phone:503-252-3906
Mailing Address - Fax:503-252-5824
Practice Address - Street 1:516 SE 71ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-2132
Practice Address - Country:US
Practice Address - Phone:503-252-3906
Practice Address - Fax:503-252-5824
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0515103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0515OtherPSYCHOLOGY LICENSE NUMBER