Provider Demographics
NPI:1578985727
Name:HATTAWAY, JACK
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:HATTAWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7160 MOON RD
Mailing Address - Street 2:SUIT G
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-1753
Mailing Address - Country:US
Mailing Address - Phone:229-357-0781
Mailing Address - Fax:
Practice Address - Street 1:7160 MOON RD
Practice Address - Street 2:SUIT G
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-1753
Practice Address - Country:US
Practice Address - Phone:229-357-0781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-07
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR009178111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor