Provider Demographics
NPI:1548644354
Name:HAVENS, JAMIE SILAS
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:SILAS
Last Name:HAVENS
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 1:49 HARTFORD AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-2756
Mailing Address - Country:US
Mailing Address - Phone:860-314-1871
Mailing Address - Fax:860-584-8425
Practice Address - Street 1:123 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-4200
Practice Address - Country:US
Practice Address - Phone:860-314-1871
Practice Address - Fax:860-584-8425
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000414237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1598891855Medicaid