Provider Demographics
NPI:1750309944
Name:HANEY, JACK (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:HANEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 TANGLEWOOD S
Mailing Address - Street 2:
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662-8244
Mailing Address - Country:US
Mailing Address - Phone:706-245-9516
Mailing Address - Fax:706-246-0900
Practice Address - Street 1:200 BOND ST
Practice Address - Street 2:STE 122
Practice Address - City:ROYSTON
Practice Address - State:GA
Practice Address - Zip Code:30662-4137
Practice Address - Country:US
Practice Address - Phone:706-246-0900
Practice Address - Fax:706-246-0900
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1193103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent