Individual
IKE JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
109 NE MANZANITA AVE, GRANTS PASS, OR 97526-1400
(541) 476-2373
Mailing address
1215 SW G ST, GRANTS PASS, OR 97526-2544
(541) 476-2373
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
101YA0400X
—
OR
Enumeration date
04/22/2022
Last updated
04/22/2022
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