Provider Demographics
NPI:1164615456
Name:HASELEY LOPEZ, JAMIE LEIGH (PHD HSPP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LEIGH
Last Name:HASELEY LOPEZ
Suffix:
Gender:F
Credentials:PHD HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 SMOKY PARK HWY
Mailing Address - Street 2:
Mailing Address - City:CANDLER
Mailing Address - State:NC
Mailing Address - Zip Code:28715-9341
Mailing Address - Country:US
Mailing Address - Phone:415-572-6450
Mailing Address - Fax:408-890-4632
Practice Address - Street 1:1528 SMOKY PARK HWY
Practice Address - Street 2:
Practice Address - City:CANDLER
Practice Address - State:NC
Practice Address - Zip Code:28715-9341
Practice Address - Country:US
Practice Address - Phone:415-572-6450
Practice Address - Fax:408-890-4632
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042197A103T00000X
IN20042197103TC2200X
NC4338103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200903840Medicaid
IN200903840Medicaid