Provider Demographics
NPI:1770607863
Name:HACK, JERRY WAYNE (LCSW, LMFT)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:WAYNE
Last Name:HACK
Suffix:
Gender:M
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 STONEYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-2108
Mailing Address - Country:US
Mailing Address - Phone:317-887-1348
Mailing Address - Fax:317-882-1631
Practice Address - Street 1:898 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1407
Practice Address - Country:US
Practice Address - Phone:317-887-1348
Practice Address - Fax:317-882-1631
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35000040A106H00000X
IN34002364A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN154024Medicare ID - Type Unspecified