Provider Demographics
NPI:1013526185
Name:WHALEN, JAMES BREWSTER (MA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:BREWSTER
Last Name:WHALEN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 CENTENNIAL BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9620 NE TANASBOURNE DR STE 300
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-7844
Practice Address - Country:US
Practice Address - Phone:541-818-0009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR7227101YP2500X, 101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500800759Medicaid