Provider Demographics
NPI:1871919167
Name:HALEY, JONATHAN D (OD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:D
Last Name:HALEY
Suffix:
Gender:M
Credentials:OD
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 O
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0212
Mailing Address - Country:US
Mailing Address - Phone:509-540-3937
Mailing Address - Fax:509-540-3938
Practice Address - Street 1:1610 PENNY LN
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362
Practice Address - Country:US
Practice Address - Phone:509-540-3937
Practice Address - Fax:509-540-3938
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003066152W00000X
WA39083152W00000X
WAOD60843163152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist