Provider Demographics
NPI:1164791992
Name:HAAKE, MARY JANE (CPCP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:HAAKE
Suffix:
Gender:F
Credentials:CPCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 SW MORRISON ST
Mailing Address - Street 2:205
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2635
Mailing Address - Country:US
Mailing Address - Phone:503-224-8416
Mailing Address - Fax:503-973-5433
Practice Address - Street 1:1017 SW MORRISON ST
Practice Address - Street 2:205
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2635
Practice Address - Country:US
Practice Address - Phone:503-224-8416
Practice Address - Fax:503-973-5433
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OREPT-T-652245246ZA2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, Medical