MEDICARE: JACKIE HAVENS

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	235Z00000X	Speech-Language Pathologist	33848	CA

General Provider Information

NPI Number	:	1770396145
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE HAVENS

Provider Business Mailing Address
First Line	:	1499 N 12TH ST
Second Line	:
City	:	EL CENTRO
State	:	CA
Zip	:	92243-1375
Country	:	US
Telephone Number	:	760-259-5316
Fax Number	:

Provider Business Practice Location Address
First Line	:	1402 W PICO AVE STE A30
Second Line	:
City	:	EL CENTRO
State	:	CA
Zip	:	92243-1377
Country	:	US
Telephone Number	:	760-259-5316
Fax Number	:

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

Provider Enumeration Date	:	01/29/2025
Last Update Date	:	01/29/2025

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Directions to “ JACKIE HAVENS ” Practice Location

Language	Start Address	Practice Location

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