1548701600 NPI number — JACKIE B MICHAEL-HAVENS NP

Table of content: JACKIE B MICHAEL-HAVENS NP (NPI 1548701600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548701600 NPI number — JACKIE B MICHAEL-HAVENS NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MICHAEL-HAVENS
Provider First Name:
JACKIE
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548701600
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 5TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKINGS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97415-9702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-412-2000
Provider Business Mailing Address Fax Number:
541-412-2081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKINGS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97415-9702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-412-2000
Provider Business Practice Location Address Fax Number:
541-412-2081
Provider Enumeration Date:
03/09/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  202000081-NP-PP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1083656367 . This is a "CURRY MEDICAL CENTER NPI" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 500776554 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1487696985 . This is a "CURRY GENERAL HOSPITAL NPI" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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