Provider Demographics
NPI:1114984176
Name:HALSTEN, JERRY W (PHD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:HALSTEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 FISH HATCHERY RD
Mailing Address - Street 2:DEAN MEDICAL CENTER
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1911
Mailing Address - Country:US
Mailing Address - Phone:608-252-8000
Mailing Address - Fax:608-252-8245
Practice Address - Street 1:1313 FISH HATCHERY RD
Practice Address - Street 2:DEAN MEDICAL CENTER
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1911
Practice Address - Country:US
Practice Address - Phone:608-252-8000
Practice Address - Fax:608-252-8245
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1820-057103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI7310OtherDEAN HEALTH INSURANCE
WI39105900Medicaid
WI680011758Medicare PIN
WI39105900Medicaid
WI059674150Medicare PIN