Provider Demographics
NPI:1760696447
Name:JARDINE, HAL J (MS)
Entity Type:Individual
Prefix:MR
First Name:HAL
Middle Name:J
Last Name:JARDINE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 N FRONT ST
Mailing Address - Street 2:
Mailing Address - City:ARCO
Mailing Address - State:ID
Mailing Address - Zip Code:83213-8756
Mailing Address - Country:US
Mailing Address - Phone:208-527-8933
Mailing Address - Fax:208-527-4481
Practice Address - Street 1:630 N FRONT ST
Practice Address - Street 2:
Practice Address - City:ARCO
Practice Address - State:ID
Practice Address - Zip Code:83213-8756
Practice Address - Country:US
Practice Address - Phone:208-527-8933
Practice Address - Fax:208-527-4481
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8063309Medicaid