Healthcare Provider Details

I. General information

NPI: 1205748753
Provider Name (Legal Business Name): JEFFREY ALAN HENNEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4570 PALISADE DR APT 10209
BOZEMAN MT
59718-2092
US

IV. Provider business mailing address

4570 PALISADE DR APT 10209
BOZEMAN MT
59718-2092
US

V. Phone/Fax

Practice location:
  • Phone: 909-319-9559
  • Fax:
Mailing address:
  • Phone: 909-319-9559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberNUR-RN-LIC-177672
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: