Provider Demographics
NPI:1447310115
Name:HENEISEN, JACK DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:DAVID
Last Name:HENEISEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2089
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-2089
Mailing Address - Country:US
Mailing Address - Phone:912-826-2132
Mailing Address - Fax:912-826-2141
Practice Address - Street 1:1214 N COLUMBIA AVE.
Practice Address - Street 2:UNIT D
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326
Practice Address - Country:US
Practice Address - Phone:912-826-2132
Practice Address - Fax:912-826-2141
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA022780207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD40117Medicare UPIN