Provider Demographics
NPI:1700400769
Name:JOHNSON, JACQUELYN L (CADC II/QMHA-II)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CADC II/QMHA-II
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:L
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CADC II/QMHA-II
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:620 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7514
Practice Address - Country:US
Practice Address - Phone:971-274-3757
Practice Address - Fax:503-912-5740
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24-QMHA-II-000217101YM0800X
OR23-05-20274101YA0400X
OR22-09-10525101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500783424Medicaid
OR500780897Medicaid