Provider Demographics
NPI:1831458272
Name:HARDEN, JAMIE LYN (DO)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYN
Last Name:HARDEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:LYN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2680 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4828
Mailing Address - Country:US
Mailing Address - Phone:269-324-2400
Mailing Address - Fax:269-324-0450
Practice Address - Street 1:2680 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4828
Practice Address - Country:US
Practice Address - Phone:269-324-2400
Practice Address - Fax:269-324-0450
Is Sole Proprietor?:No
Enumeration Date:2012-05-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019796390200000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program