Provider Demographics
NPI:1417940172
Name:HAGGENJOS, JEFFREY JORDAN (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JORDAN
Last Name:HAGGENJOS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 231
Mailing Address - Street 2:
Mailing Address - City:NEW LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43764-0231
Mailing Address - Country:US
Mailing Address - Phone:740-856-8253
Mailing Address - Fax:
Practice Address - Street 1:775 CARROLL ST
Practice Address - Street 2:
Practice Address - City:NEW LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:43764-9415
Practice Address - Country:US
Practice Address - Phone:740-856-8253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-002872207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0400293Medicaid
OH0400293Medicaid
E00643Medicare UPIN
OH0466697Medicare PIN