Provider Demographics
NPI:1770745457
Name:JOHNSON, JACKIE EUGENE SR (CADC II/QMHP-C, CSWA)
Entity type:Individual
Prefix:MR
First Name:JACKIE
Middle Name:EUGENE
Last Name:JOHNSON
Suffix:SR
Gender:M
Credentials:CADC II/QMHP-C, CSWA
Other - Prefix:MR
Other - First Name:JACK
Other - Middle Name:EUGENE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CADC II/QMHP-R
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 1:355 NW DIVISION ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5523
Practice Address - Country:US
Practice Address - Phone:503-231-2641
Practice Address - Fax:503-231-1654
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17-CRM-078101YA0400X
OR24-QMHPC-001514101YM0800X
ORA117501041C0700X
OR00-11-45101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500800849Medicaid
OR500801135Medicaid