Provider Demographics
NPI:1790519734
Name:HAINES, JACQUELYN LORRAINE
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:LORRAINE
Last Name:HAINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 PACIFIC AVE STE 212
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-4433
Mailing Address - Country:US
Mailing Address - Phone:253-777-4742
Mailing Address - Fax:253-888-3572
Practice Address - Street 1:917 PACIFIC AVE STE 212
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4433
Practice Address - Country:US
Practice Address - Phone:253-777-4742
Practice Address - Fax:253-888-3572
Is Sole Proprietor?:No
Enumeration Date:2024-08-30
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61625174175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist