Healthcare Provider Details

I. General information

NPI: 1235302902
Provider Name (Legal Business Name): JEAN HA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR BUILDING 2059, ATTN:MCXE-PMD-PHN-HA
FT CARSON CO
80913-4603
US

IV. Provider business mailing address

1650 COCHRANE CIR BUILDING 2059, ATTN:MCXE-PMD-PHN-HA
FT CARSON CO
80913-4603
US

V. Phone/Fax

Practice location:
  • Phone: 719-524-0727
  • Fax:
Mailing address:
  • Phone: 719-524-0727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number175234
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: