Provider Demographics
NPI:1366927766
Name:HANEY, JESSICA LEIGH
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:HANEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5779 MACLAND RD
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-4128
Mailing Address - Country:US
Mailing Address - Phone:770-900-2080
Mailing Address - Fax:
Practice Address - Street 1:7810 HIGHWAY 85
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-3920
Practice Address - Country:US
Practice Address - Phone:770-473-7833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN205930363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily