Provider Demographics
NPI:1669651543
Name:JOHNSON, JASON ALAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:ALAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 SW TAYLOR ST STE 245
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2507
Mailing Address - Country:US
Mailing Address - Phone:503-853-4998
Mailing Address - Fax:
Practice Address - Street 1:1020 SW TAYLOR ST STE 245
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2507
Practice Address - Country:US
Practice Address - Phone:503-853-4998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR08-08-25101YA0400X
101YM0800X, 171M00000X, 174400000X
OR3055103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174400000XOther Service ProvidersSpecialist