Provider Demographics
NPI:1497751754
Name:HANEY, JESSICA (OD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HANEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 GERMANTOWN PIKE
Mailing Address - Street 2:STE 200
Mailing Address - City:LAFAYETTE HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19444-1816
Mailing Address - Country:US
Mailing Address - Phone:610-825-8210
Mailing Address - Fax:610-825-8208
Practice Address - Street 1:413 GERMANTOWN PIKE
Practice Address - Street 2:STE 200
Practice Address - City:LAFAYETTE HILL
Practice Address - State:PA
Practice Address - Zip Code:19444-1816
Practice Address - Country:US
Practice Address - Phone:610-825-8210
Practice Address - Fax:610-825-8208
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00583900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0004570Medicaid
NJ070774Medicare ID - Type UnspecifiedINDIV NJ MEDICARE NUMBER
NJ0004570Medicaid