Provider Demographics
NPI:1780485094
Name:JOHNSON, MANDY LYNN (PEER SUPPORT SPECIAL)
Entity type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:
Credentials:PEER SUPPORT SPECIAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36542 HIGHWAY 58
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:OR
Mailing Address - Zip Code:97455-9689
Mailing Address - Country:US
Mailing Address - Phone:541-606-2919
Mailing Address - Fax:
Practice Address - Street 1:36542 HIGHWAY 58
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:OR
Practice Address - Zip Code:97455-9689
Practice Address - Country:US
Practice Address - Phone:541-606-2919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-22
Last Update Date:2025-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR113576175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist