Provider Demographics
NPI:1861482002
Name:HALING, JACK LEROY (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:LEROY
Last Name:HALING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-0339
Mailing Address - Country:US
Mailing Address - Phone:530-926-5613
Mailing Address - Fax:530-926-8798
Practice Address - Street 1:824 PINE ST
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2137
Practice Address - Country:US
Practice Address - Phone:530-926-4528
Practice Address - Fax:530-926-5070
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC28244208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C282440Medicaid
CA00C282440Medicaid
CA00C282440Medicare ID - Type Unspecified