Healthcare Provider Details

I. General information

NPI: 1851226526
Provider Name (Legal Business Name): JAMES M HENNEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19600 SW STACEY ST
BEAVERTON OR
97003-2520
US

IV. Provider business mailing address

19600 SW STACEY ST
BEAVERTON OR
97003-2520
US

V. Phone/Fax

Practice location:
  • Phone: 503-649-6287
  • Fax: 503-591-7489
Mailing address:
  • Phone: 503-649-6287
  • Fax: 503-591-7489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number100085
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: