Healthcare Provider Details

I. General information

NPI: 1962931154
Provider Name (Legal Business Name): JESSICA MICHAELA HENNAGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 06/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 EASTSIDE HWY
CORVALLIS MT
59828-9616
US

IV. Provider business mailing address

2200 EASTSIDE HWY
CORVALLIS MT
59828-9616
US

V. Phone/Fax

Practice location:
  • Phone: 406-360-8221
  • Fax: 406-360-8221
Mailing address:
  • Phone: 406-360-8221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: