=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366927766
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA LEIGH HANEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2018
-----------------------------------------------------
Last Update Date | 10/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7810 HIGHWAY 85
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30274-3920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-473-7833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5779 MACLAND RD
-----------------------------------------------------
City | POWDER SPRINGS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30127-4128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-900-2080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN-NP205930
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------