Provider Demographics
NPI:1528385523
Name:HALEY, JILLIAN K
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:K
Last Name:HALEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 MADORA AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-3057
Mailing Address - Country:US
Mailing Address - Phone:307-358-2846
Mailing Address - Fax:
Practice Address - Street 1:1841 MADORA AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-3057
Practice Address - Country:US
Practice Address - Phone:307-358-2846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1225003023Medicaid
WY1932229523Medicaid