Individual
JOHNATHON MICHAEL JACOBSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
912 NE KELLY AVE # 100C, GRESHAM, OR 97030-5629
(503) 912-5502
Mailing address
4920 NE GLISAN ST APT 215, PORTLAND, OR 97213-2964
(720) 633-4818
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
10212054
OR
Other
Enumeration date
01/08/2021
Last updated
01/08/2021
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