NPIMap

Individual provider Active NPI

Jacqueline Marie Johnson, D.O.

  • Family Medicine Physician
  • Myrtle Creek, OR
National Provider Identifier
1083814099
Registry record updated Aug 9, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
DO161555 Issued in OR
Practice address
145 NE Broadway St
Myrtle Creek, OR 97457-9039
Phone
(541) 677-7200
Fax
(541) 229-3309
NPI assigned
Jul 19, 2007
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Aug 9, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X O-0482 ID
Family Medicine Physician 207Q00000X DO161555 OR Primary

Addresses

Primary practice location

145 NE Broadway St
Myrtle Creek, OR 97457-9039

Mailing address

2570 NW Edenbower Blvd Ste 100
Roseburg, OR 97471-6214
Phone (541) 677-7200

Other names 1

  • Jacqueline Varnell Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20130703000184 OR Practitioner - Family Practice 0244470805 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
At Still University of Health Sciences, College of Osteo Med, Kirksville, 2006
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Centennial Medical Group East LLCGroup PAC ID 9234397878, 63 clinicians
Evergreen Family Medicine PCGroup PAC ID 3870485139, 55 clinicians

Practice addresses (Care Compare)

145 NE Broadway St
Myrtle Creek, OR 97457-9039
Phone (541) 677-7200

2570 NW Edenbower Blvd
Roseburg, OR 97471-6214

Hospital & facility affiliations

  • Amedisys Home Health Care Home health agency, Roseburg, OR, CCN 387311
  • Amedisys Hospice Care Hospice, Roseburg, OR, CCN 381518
  • Mercy Medical Center Hospital, Roseburg, OR, CCN 380027
  • Asante Three Rivers Medical Center Hospital, Grants Pass, OR, CCN 380002
  • Sacred Heart Medical Center - Riverbend Hospital, Springfield, OR, CCN 380102
  • Rose Haven Nursing Center Nursing home, Roseburg, OR, CCN 385151

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

State licenses

LicenseStateTypeSpecialty
O-0482IDMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Centennial Medical Group East, LLC Family Medicine Current Accepting new patients
Centennial Medical Group East, LLC Family Medicine CurrentSince Aug 1, 2023 Accepting new patients
Centennial Medical Group East, LLC Family Medicine CurrentSince Aug 1, 2023 Accepting new patients

Locations

145 NE Broadway St
Myrtle Creek, OR 97457
Phone (541) 677-7200

2570 NW Edenbower Blvd
Ste 100
Roseburg, OR 97471
Phone (541) 677-7200

Interoperability endpoints

  • Direct secure messaging: jacqueline.johnson.1@1334.direct.athenahealth.com

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1184803200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1691539200000",
    "number": "1083814099",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2570 NW EDENBOWER BLVD STE 100",
            "city": "ROSEBURG",
            "state": "OR",
            "postal_code": "974716214",
            "telephone_number": "541-677-7200",
            "fax_number": "541-229-3309"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "145 NE BROADWAY ST",
            "city": "MYRTLE CREEK",
            "state": "OR",
            "postal_code": "974579039",
            "telephone_number": "541-677-7200",
            "fax_number": "541-229-3309"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JOHNSON",
        "first_name": "JACQUELINE",
        "middle_name": "MARIE",
        "name_prefix": "Dr.",
        "credential": "D.O.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-07-19",
        "last_updated": "2023-08-09",
        "certification_date": "2023-08-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "ID",
            "license": "O-0482",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "OR",
            "license": "DO161555",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "JACQUELINE",
            "last_name": "VARNELL",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in Myrtle Creek, OR

Sources for this page

Verify at the official NPI Registry.