Basic Information
| Provider Information | |||||||||
| NPI: | 1407498074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSTON | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | BENJAMIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1525 PLAZA ST NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973044614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038778567 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1233 EDGEWATER ST NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973044049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033787526 | ||||||||
| FaxNumber: | 5034801611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2019 | ||||||||
| LastUpdateDate: | 07/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3747A0650X | N | Nursing Service Related Providers | Technician | Attendant Care Provider | 172V00000X | THW000002220 | OR | Y | Other Service Providers | Community Health Worker |
No ID Information.