MEDICARE: DR. JACK HANEY PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	1193	GA
2	103TC2200X	Clinical Child & Adolescent Psychologist	1193	GA

General Provider Information

NPI Number	:	1750309944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK HANEY PH.D.

Provider Business Mailing Address
First Line	:	248 TANGLEWOOD S
Second Line	:
City	:	ROYSTON
State	:	GA
Zip	:	30662-8244
Country	:	US
Telephone Number	:	706-245-9516
Fax Number	:	706-246-0900

Provider Business Practice Location Address
First Line	:	200 BOND ST
Second Line	:	STE 122
City	:	ROYSTON
State	:	GA
Zip	:	30662-4137
Country	:	US
Telephone Number	:	706-246-0900
Fax Number	:	706-246-0900

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	09/11/2025

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