MEDICARE: DR. JACK DAVID HENEISEN M.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	207Q00000X	Family Medicine Physician	022780	GA

General Provider Information

NPI Number	:	1447310115
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK DAVID HENEISEN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 2089
Second Line	:
City	:	RINCON
State	:	GA
Zip	:	31326-2089
Country	:	US
Telephone Number	:	912-826-2132
Fax Number	:	912-826-2141

Provider Business Practice Location Address
First Line	:	1214 N COLUMBIA AVE.
Second Line	:	UNIT D
City	:	RINCON
State	:	GA
Zip	:	31326
Country	:	US
Telephone Number	:	912-826-2132
Fax Number	:	912-826-2141

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	07/08/2007

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