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General NPI Number Information
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NPI Number | 1548701600
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Entity Type | Individual
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Provider Name | JACKIE B MICHAEL-HAVENS NP
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Gender | Female
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Dates
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Enumeration Date | 03/09/2017
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Last Update Date | 09/03/2020
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Provider Practice Location Address
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Address Line | 500 5TH ST
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City | BROOKINGS
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State | OR
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Zip | 97415-9702
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Country | US
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Telephone | 541-412-2000
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Fax | 541-412-2081
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Provider Business Mailing Address
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Address Line | 500 5TH ST
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City | BROOKINGS
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State | OR
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Zip | 97415-9702
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Country | US
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Telephone | 541-412-2000
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Fax | 541-412-2081
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 202000081-NP-PP
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License Number State | OR
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