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General NPI Number Information
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NPI Number | 1942338785
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Entity Type | Individual
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Provider Name | JACKSON LEE HAVERLY M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/02/2007
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Last Update Date | 07/29/2008
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Provider Practice Location Address
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Address Line | 22410 BENSON RD SE BENSON HEIGHTS REHAB CENTER
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City | KENT
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State | WA
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Zip | 98031-9509
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Country | US
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Telephone | 206-286-8352
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Fax |
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Provider Business Mailing Address
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Address Line | 10611 CANYON RD E PMB 322
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City | PUYALLUP
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State | WA
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Zip | 98373-4256
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Country | US
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Telephone | 206-286-8352
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 00030718
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License Number State | WA
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