Basic Information
| Provider Information | |||||||||
| NPI: | 1952360422 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALVERSON | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34700 VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530664500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626464411 | ||||||||
| FaxNumber: | 2626461076 | ||||||||
| Practice Location | |||||||||
| Address1: | 34700 VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530664500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626464411 | ||||||||
| FaxNumber: | 2626461076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 05/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084A0401X | 43851 | WI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 2084P0015X | 43851 | WI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychosomatic Medicine | 2084P0800X | 43851 | WI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.