Provider Demographics
NPI:1255365359
Name:HAFER, KATHRYN JEAN (DC)
Entity type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:JEAN
Last Name:HAFER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 S WESTNEDGE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008
Mailing Address - Country:US
Mailing Address - Phone:269-383-4325
Mailing Address - Fax:616-396-0486
Practice Address - Street 1:1122 S WESTNEDGE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008
Practice Address - Country:US
Practice Address - Phone:269-383-4325
Practice Address - Fax:269-383-4325
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301300275111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3455962Medicaid
MI950C950120OtherBCROSS
MIP71224OtherBSHIELD
T33621Medicare UPIN