Provider Demographics
NPI:1093232688
Name:EVANS, HALEY JORDAN
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:JORDAN
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2806 MATTHEW DR
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-7981
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 W LAMINE ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:MO
Practice Address - Zip Code:65338-1101
Practice Address - Country:US
Practice Address - Phone:660-547-3514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017028891225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist