Provider Demographics
NPI:1215618327
Name:HALEY, JONATHAN ANDREW
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ANDREW
Last Name:HALEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JONATHAN
Other - Middle Name:ANDREW
Other - Last Name:HALEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4577 W PECOS RD
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-9002
Mailing Address - Country:US
Mailing Address - Phone:520-550-6423
Mailing Address - Fax:520-550-6033
Practice Address - Street 1:4577 W PECOS RD
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-9002
Practice Address - Country:US
Practice Address - Phone:520-550-6423
Practice Address - Fax:520-550-6033
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLASAC15316101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)