Basic Information
| Provider Information | |||||||||
| NPI: | 1407943152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARDEE | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | FAULK | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4947 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312084947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783014111 | ||||||||
| FaxNumber: | 4783012272 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 FIRST STREET | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783015930 | ||||||||
| FaxNumber: | 4783015932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 10/29/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW000304 | GA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | MFT000169 | GA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000748811A | 05 | GA | MEDICAID | 800007277 | 01 | GA | RAILROAD MEDICARE | OTHER |