Provider Demographics
NPI:1033610415
Name:THOMAS, DERRICK JACKSON (ATC)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:JACKSON
Last Name:THOMAS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BONNYBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PORT WENTWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-1312
Mailing Address - Country:US
Mailing Address - Phone:704-796-9595
Mailing Address - Fax:
Practice Address - Street 1:1 BONNYBRIDGE RD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31407-1312
Practice Address - Country:US
Practice Address - Phone:704-796-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0031162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer