Provider Demographics
NPI:1023463908
Name:HAYNES, JEFFREY EMIL
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:EMIL
Last Name:HAYNES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 S TILDEN ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-1863
Mailing Address - Country:US
Mailing Address - Phone:248-745-4900
Mailing Address - Fax:248-994-4616
Practice Address - Street 1:38855 HILLS TECH DR STE 200
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-3428
Practice Address - Country:US
Practice Address - Phone:248-745-4900
Practice Address - Fax:248-994-4616
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704203472163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health