Provider Demographics
NPI:1407943152
Name:HARDEE, JANE FAULK (LCSW)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:FAULK
Last Name:HARDEE
Suffix:
Gender:F
Credentials:LCSW
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 4947
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4947
Mailing Address - Country:US
Mailing Address - Phone:478-301-4111
Mailing Address - Fax:478-301-2272
Practice Address - Street 1:655 FIRST STREET
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-301-5930
Practice Address - Fax:478-301-5932
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0003041041C0700X
GAMFT000169106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000748811AMedicaid
GA800007277OtherRAILROAD MEDICARE
GA80BBDLXMedicare PIN
S34072Medicare UPIN