Active NPI
Jack Eugene Johnson Sr., CADC II/QMHP-C, CSWA
- Addiction (Substance Use Disorder) Counselor
- Gresham, OR
National Provider Identifier
1770745457
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Addiction (Substance Use Disorder) Counselor
- License
- 00-11-45
- Practice address
- 355 NW Division St
Gresham, OR 97030-5523 - Phone
- (503) 231-2641
- Fax
- (503) 231-1654
- NPI assigned
- Jun 25, 2008
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Addiction (Substance Use Disorder) Counselor | 101YA0400X | 00-11-45 | OR | Primary |
| Clinical Social Worker | 1041C0700X | A11750 | OR | |
| Mental Health Counselor | 101YM0800X | 24-QMHPC-001514 | OR |
Addresses
Primary practice location
355 NW Division St
Gresham, OR 97030-5523
Mailing address
1776 SW Madison St
Portland, OR 97205-1715
Phone (503) 224-1044
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 500800849 | Medicaid | OR | |
| 500801135 | Medicaid | OR |
Other names 1
- Mr. Jackie Eugene Johnson
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 17-CRM-078 | OR | MD | Addiction (Substance Use Disorder) Counselor |
| 24-QMHPC-001514 | OR | MD | Mental Health Counselor |
| A11750 | OR | MD | Clinical Social Worker |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1214352000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1785715200000",
"number": "1770745457",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1776 SW MADISON ST",
"city": "PORTLAND",
"state": "OR",
"postal_code": "972051715",
"telephone_number": "503-224-1044",
"fax_number": "503-621-2235"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "355 NW DIVISION ST",
"city": "GRESHAM",
"state": "OR",
"postal_code": "970305523",
"telephone_number": "503-231-2641",
"fax_number": "503-231-1654"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JOHNSON",
"first_name": "JACK",
"middle_name": "EUGENE",
"name_prefix": "Mr.",
"name_suffix": "Sr.",
"credential": "CADC II/QMHP-C, CSWA",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2008-06-25",
"last_updated": "2026-08-03",
"certification_date": "2026-08-03",
"status": "A"
},
"taxonomies": [
{
"code": "101YA0400X",
"taxonomy_group": "",
"desc": "Counselor, Addiction (Substance Use Disorder)",
"state": "OR",
"license": "00-11-45",
"primary": true
},
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "OR",
"license": "A11750",
"primary": false
},
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "OR",
"license": "24-QMHPC-001514",
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "500800849",
"state": "OR"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "500801135",
"state": "OR"
}
],
"endpoints": [],
"other_names": [
{
"first_name": "JACKIE",
"last_name": "JOHNSON",
"middle_name": "EUGENE",
"prefix": "MR.",
"credential": "CADC II/QMHP-R",
"code": "2",
"type": "Professional Name"
}
]
}Other providers in Gresham, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 3, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.