Healthcare Provider Details

I. General information

NPI: 1801711072
Provider Name (Legal Business Name): STAG CREST PATHWAYS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5541 S MACADAM AVE # 6426
PORTLAND OR
97239-6106
US

IV. Provider business mailing address

5541 S MACADAM AVE # 6426
PORTLAND OR
97239-6106
US

V. Phone/Fax

Practice location:
  • Phone: 971-200-5126
  • Fax:
Mailing address:
  • Phone: 971-200-5126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: ABDIFATAH JAMA
Title or Position: OWNER
Credential:
Phone: 971-200-5126