Provider Demographics
NPI:1871937078
Name:HERSOM, JUSTIN I (LCSW)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:I
Last Name:HERSOM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17250 WILSON RIVER HWY
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-9145
Mailing Address - Country:US
Mailing Address - Phone:832-326-8552
Mailing Address - Fax:503-842-5035
Practice Address - Street 1:17250 WILSON RIVER HWY
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-9145
Practice Address - Country:US
Practice Address - Phone:832-326-8552
Practice Address - Fax:503-842-5035
Is Sole Proprietor?:No
Enumeration Date:2013-04-18
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX552021041C0700X, 104100000X
OR60511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker