Provider Demographics
NPI:1033806021
Name:HAEN, JACKSON EDGAR
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:EDGAR
Last Name:HAEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-2451
Mailing Address - Country:US
Mailing Address - Phone:720-256-4685
Mailing Address - Fax:
Practice Address - Street 1:552 N PINE ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-2451
Practice Address - Country:US
Practice Address - Phone:720-256-4685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist