Provider Demographics
NPI:1447205273
Name:HALVERSON, JAIME (DO)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:HALVERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:1175 WILSON AVE NW
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MI
Practice Address - Zip Code:49534-3493
Practice Address - Country:US
Practice Address - Phone:616-685-8650
Practice Address - Fax:616-791-2160
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014826207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4891070Medicaid
MI4891052Medicaid
MI4893217Medicaid
MI4890959Medicaid
MI4890995Medicaid
MI4891061Medicaid
MI4891052Medicaid
MI4890959Medicaid
MI4891070Medicaid