Basic Information
| Provider Information | |||||||||
| NPI: | 1962722561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | KIMBERLEY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STAPLES | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | KIMBERLEY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2051 KAEN RD | ||||||||
| Address2: | SUITE 367 | ||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037425300 | ||||||||
| FaxNumber: | 5036558500 | ||||||||
| Practice Location | |||||||||
| Address1: | 1002 LIBRARY CT | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036558264 | ||||||||
| FaxNumber: | 5036558428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2010 | ||||||||
| LastUpdateDate: | 09/26/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | L4577 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.