Healthcare Provider Details

I. General information

NPI: 1952360422
Provider Name (Legal Business Name): JERRY LEE HALVERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34700 VALLEY RD
OCONOMOWOC WI
53066-4500
US

IV. Provider business mailing address

34700 VALLEY RD
OCONOMOWOC WI
53066-4500
US

V. Phone/Fax

Practice location:
  • Phone: 262-646-4411
  • Fax: 262-646-1076
Mailing address:
  • Phone: 262-646-4411
  • Fax: 262-646-1076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number43851
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number43851
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number43851
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: