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General NPI Number Information
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NPI Number | 1659819076
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Entity Type | Individual
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Provider Name | HALEY JACOB
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Gender | Female
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Dates
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Enumeration Date | 02/06/2017
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Last Update Date | 02/06/2017
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Provider Practice Location Address
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Address Line | 1725 STATE ST 126 MITCHELL HALL
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City | LA CROSSE
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State | WI
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Zip | 54601-3742
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Country | US
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Telephone | 216-978-1173
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Fax |
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Provider Business Mailing Address
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Address Line | 18442 HIGH PKWY
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City | ROCKY RIVER
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State | OH
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Zip | 44116-2829
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Country | US
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Telephone |
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Fax |
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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 | 405300000X
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Taxonomy Name | Prevention Professional
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License Number | 1901-39
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License Number State | WI
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