Basic Information
Provider Information | |||||||||
NPI: | 1548701600 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MICHAEL-HAVENS | ||||||||
FirstName: | JACKIE | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 5TH ST | ||||||||
Address2: |   | ||||||||
City: | BROOKINGS | ||||||||
State: | OR | ||||||||
PostalCode: | 974159702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5414122000 | ||||||||
FaxNumber: | 5414122081 | ||||||||
Practice Location | |||||||||
Address1: | 500 5TH ST | ||||||||
Address2: |   | ||||||||
City: | BROOKINGS | ||||||||
State: | OR | ||||||||
PostalCode: | 974159702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5414122000 | ||||||||
FaxNumber: | 5414122081 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2017 | ||||||||
LastUpdateDate: | 09/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 202000081-NP-PP | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 1083656367 | 01 | OR | CURRY MEDICAL CENTER NPI | OTHER | 500776554 | 05 | OR |   | MEDICAID | 1487696985 | 01 | OR | CURRY GENERAL HOSPITAL NPI | OTHER |