Provider Demographics
NPI:1144945296
Name:JOHNSON, DAMION
Entity type:Individual
Prefix:
First Name:DAMION
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5852 NE AINSWORTH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-2354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2355 STATE ST STE 101
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4541
Practice Address - Country:US
Practice Address - Phone:503-749-5760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR104100000X, 172A00000X, 175T00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No172A00000XOther Service ProvidersDriver
No175T00000XOther Service ProvidersPeer Specialist