Provider Demographics
NPI:1619438991
Name:HALEY, JARED MICHAEL (CSA)
Entity Type:Individual
Prefix:MR
First Name:JARED
Middle Name:MICHAEL
Last Name:HALEY
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 WOODCHASE WAY
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-2052
Mailing Address - Country:US
Mailing Address - Phone:678-956-1272
Mailing Address - Fax:
Practice Address - Street 1:403 WOODCHASE WAY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-2052
Practice Address - Country:US
Practice Address - Phone:678-956-1272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
5008246ZC0007X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant