Provider Demographics
NPI:1043626997
Name:HAILEY, JEROME C
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:C
Last Name:HAILEY
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 1:215 DANIELS AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1513
Mailing Address - Country:US
Mailing Address - Phone:860-558-9143
Mailing Address - Fax:
Practice Address - Street 1:215 DANIELS AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1513
Practice Address - Country:US
Practice Address - Phone:860-558-9143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-10
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker