Provider Demographics
NPI:1760840896
Name:JOHNSON, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21112
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-0356
Mailing Address - Country:US
Mailing Address - Phone:678-687-8196
Mailing Address - Fax:
Practice Address - Street 1:485 ALEXANDER LOOP STE 110
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6753
Practice Address - Country:US
Practice Address - Phone:541-423-7009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-03
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR46-2071391225700000X
OR19559225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty