Basic Information
| Provider Information | |||||||||
| NPI: | 1114984176 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HALSTEN | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1313 FISH HATCHERY RD | ||||||||
| Address2: | DEAN MEDICAL CENTER | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082528000 | ||||||||
| FaxNumber: | 6082528245 | ||||||||
| Practice Location | |||||||||
| Address1: | 1313 FISH HATCHERY RD | ||||||||
| Address2: | DEAN MEDICAL CENTER | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082528000 | ||||||||
| FaxNumber: | 6082528245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 1820-057 | WI | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 7310 | 01 | WI | DEAN HEALTH INSURANCE | OTHER | 39105900 | 05 | WI | MEDICAID |