Healthcare Provider Details

I. General information

NPI: 1730102245
Provider Name (Legal Business Name): JONATHAN D. HAUSER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 03/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DEVANT STREET STE 705 CARNEGIE BEHAVIORAL HEALTH
FAYETTEVILLE GA
30214-2717
US

IV. Provider business mailing address

101 DEVANT STREET STE 705 CARNEGIE BEHAVIORAL HEALTH
FAYETTEVILLE GA
30214-2717
US

V. Phone/Fax

Practice location:
  • Phone: 770-716-6012
  • Fax: 770-716-6013
Mailing address:
  • Phone: 770-716-6012
  • Fax: 770-716-6013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number002374
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberGA002374
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: