Provider Demographics
NPI:1699363143
Name:JACOBSEN, JOHNATHON MICHAEL
Entity type:Individual
Prefix:
First Name:JOHNATHON
Middle Name:MICHAEL
Last Name:JACOBSEN
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 1:4920 NE GLISAN ST APT 215
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2964
Mailing Address - Country:US
Mailing Address - Phone:720-633-4818
Mailing Address - Fax:
Practice Address - Street 1:912 NE KELLY AVE # 100C
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5629
Practice Address - Country:US
Practice Address - Phone:503-912-5502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10212054106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician