Provider Demographics
NPI:1477529519
Name:HALEY, JACK M
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:M
Last Name:HALEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:M
Other - Last Name:HALEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:P.O. BOX 173817
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-8643
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:2000 N. BOISE AVE.
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-7282
Practice Address - Country:US
Practice Address - Phone:970-635-4071
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO735363A00000X
COPA.000735363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP01331724OtherRAILROAD MEDICARE
CO55625029Medicaid
CO55625029Medicaid
CO349413YL4CMedicare PIN