Provider Demographics
NPI:1942338785
Name:HAVERLY, JACKSON LEE (MD)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:LEE
Last Name:HAVERLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10611 CANYON RD E
Mailing Address - Street 2:PMB 322
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-4256
Mailing Address - Country:US
Mailing Address - Phone:206-286-8352
Mailing Address - Fax:
Practice Address - Street 1:22410 BENSON RD SE
Practice Address - Street 2:BENSON HEIGHTS REHAB CENTER
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98031-9509
Practice Address - Country:US
Practice Address - Phone:206-286-8352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA000307182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAE 51522Medicare UPIN