Provider Demographics
NPI:1912414889
Name:JEROMY T HACKNEY, MD, PA
Entity type:Organization
Organization Name:JEROMY T HACKNEY, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROMY
Authorized Official - Middle Name:T
Authorized Official - Last Name:HACKNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-998-4440
Mailing Address - Street 1:133 N FRIENDSWOOD DR # 326
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-3746
Mailing Address - Country:US
Mailing Address - Phone:832-998-4440
Mailing Address - Fax:
Practice Address - Street 1:8 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4127
Practice Address - Country:US
Practice Address - Phone:281-724-5120
Practice Address - Fax:281-724-5119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP9582208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty