Provider Demographics
NPI:1184068793
Name:ACKLEY, JOHN (CADC II, CGAC I,QMHA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ACKLEY
Suffix:
Gender:M
Credentials:CADC II, CGAC I,QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3878 BEVERLY AVE NE
Mailing Address - Street 2:BLDG H, SUITE 5
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1394
Mailing Address - Country:US
Mailing Address - Phone:503-399-0670
Mailing Address - Fax:503-399-0655
Practice Address - Street 1:3878 BEVERLY AVE NE
Practice Address - Street 2:BLDG H, SUITE 5
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1394
Practice Address - Country:US
Practice Address - Phone:503-399-0670
Practice Address - Fax:503-399-0655
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12-06-75U101YA0400X
OR101YM0800X
ORG 16-04-01101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health