Healthcare Provider Details

I. General information

NPI: 1336004233
Provider Name (Legal Business Name): JESSICA HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MARCELO HERNANDEZ

II. Dates (important events)

Enumeration Date: 12/22/2025
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 NW WALNUT BLVD APT 71
CORVALLIS OR
97330-3298
US

IV. Provider business mailing address

4400 NW WALNUT BLVD APT 71
CORVALLIS OR
97330-3298
US

V. Phone/Fax

Practice location:
  • Phone: 541-740-0708
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: