MEDICARE: JEFFREY EMIL HAYNES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0808X	Psychiatric/Mental Health Registered Nurse	4704203472	MI

General Provider Information

NPI Number	:	1023463908
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY EMIL HAYNES

Provider Business Mailing Address
First Line	:	250 S TILDEN ST
Second Line	:
City	:	PONTIAC
State	:	MI
Zip	:	48341-1863
Country	:	US
Telephone Number	:	248-745-4900
Fax Number	:	248-994-4616

Provider Business Practice Location Address
First Line	:	38855 HILLS TECH DR STE 200
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48331-3428
Country	:	US
Telephone Number	:	248-745-4900
Fax Number	:	248-994-4616

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2016
Last Update Date	:	04/28/2016

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