1780129064 NPI number — JORDAN E HAIRE

Table of content: JORDAN E HAIRE (NPI 1780129064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780129064 NPI number — JORDAN E HAIRE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAIRE
Provider First Name:
JORDAN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1780129064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
474 N YELLOW SPRINGS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45504-2463
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-399-9500
Provider Business Mailing Address Fax Number:
937-342-4242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 WELLNESS WAY
Provider Second Line Business Practice Location Address:
410
Provider Business Practice Location Address City Name:
NEAH BAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98357-9835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-645-3010
Provider Business Practice Location Address Fax Number:
360-645-3343
Provider Enumeration Date:
12/22/2016

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: 101YP2500X , with the licence number:  C.1200640 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: LH60728422 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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