Active NPI
Jackson Lee Haverly, M.D.
- Psychiatry Physician
- Kent, WA
National Provider Identifier
1942338785
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychiatry Physician
- License
- 00030718
- Practice address
- 22410 Benson Rd SE
Benson Heights Rehab Center
Kent, WA 98031-9509 - Phone
- (206) 286-8352
- NPI assigned
- Mar 2, 2007
- Last updated
- Jul 29, 2008
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychiatry Physician | 2084P0800X | 00030718 | WA | Primary |
Addresses
Primary practice location
22410 Benson Rd SE
Benson Heights Rehab Center
Kent, WA 98031-9509
Mailing address
10611 Canyon Rd E
PMB 322
Puyallup, WA 98373-4256
Phone (206) 286-8352
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 00030718 | WA | MD | Psychiatry Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1172793600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1217289600000",
"number": "1942338785",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "10611 CANYON RD E",
"address_2": "PMB 322",
"city": "PUYALLUP",
"state": "WA",
"postal_code": "983734256",
"telephone_number": "206-286-8352"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "22410 BENSON RD SE",
"address_2": "BENSON HEIGHTS REHAB CENTER",
"city": "KENT",
"state": "WA",
"postal_code": "980319509",
"telephone_number": "206-286-8352"
}
],
"practiceLocations": [],
"basic": {
"last_name": "HAVERLY",
"first_name": "JACKSON",
"middle_name": "LEE",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-03-02",
"last_updated": "2008-07-29",
"status": "A"
},
"taxonomies": [
{
"code": "2084P0800X",
"taxonomy_group": "",
"desc": "Psychiatry & Neurology, Psychiatry",
"state": "WA",
"license": "00030718",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Kent, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 29, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.