Healthcare Provider Details

I. General information

NPI: 1366648834
Provider Name (Legal Business Name): JAMIE L HAYNES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAMIE L WILSON

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 4TH ST STOP 8143
LUBBOCK TX
79430-0002
US

IV. Provider business mailing address

3601 4TH ST STOP 8143
LUBBOCK TX
79430-0002
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-2757
  • Fax: 806-743-1180
Mailing address:
  • Phone: 806-743-2775
  • Fax: 806-743-1421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberN1345
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00046932
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: