Provider Demographics
NPI:1679187728
Name:HALSEY, JONATHAN ROBERT
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ROBERT
Last Name:HALSEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:688 FOXWORTH ST
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:MI
Mailing Address - Zip Code:48131-9403
Mailing Address - Country:US
Mailing Address - Phone:517-795-9355
Mailing Address - Fax:
Practice Address - Street 1:688 FOXWORTH ST
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:MI
Practice Address - Zip Code:48131-9403
Practice Address - Country:US
Practice Address - Phone:517-795-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-06
Last Update Date:2020-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer