Healthcare Provider Details

I. General information

NPI: 1457129256
Provider Name (Legal Business Name): JENNIFER HALLER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E WILLETTA ST FL 1
PHOENIX AZ
85006-2516
US

IV. Provider business mailing address

530 E MARIPOSA ST APT 48
PHOENIX AZ
85012-1639
US

V. Phone/Fax

Practice location:
  • Phone: 602-839-6900
  • Fax:
Mailing address:
  • Phone: 480-437-0594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19016
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: