Provider Demographics
NPI:1548701600
Name:MICHAEL-HAVENS, JACKIE B (NP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:B
Last Name:MICHAEL-HAVENS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-9702
Mailing Address - Country:US
Mailing Address - Phone:541-412-2000
Mailing Address - Fax:541-412-2081
Practice Address - Street 1:500 5TH ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9702
Practice Address - Country:US
Practice Address - Phone:541-412-2000
Practice Address - Fax:541-412-2081
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202000081-NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1083656367OtherCURRY MEDICAL CENTER NPI
OR500776554Medicaid
OR1487696985OtherCURRY GENERAL HOSPITAL NPI