Provider Demographics
NPI:1043664741
Name:STEVENS, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:STEVENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 HIGHWAY 74 S
Mailing Address - Street 2:SUITE 720
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-3081
Mailing Address - Country:US
Mailing Address - Phone:678-595-3863
Mailing Address - Fax:
Practice Address - Street 1:611 HIGHWAY 74 S
Practice Address - Street 2:SUITE 720
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3081
Practice Address - Country:US
Practice Address - Phone:678-595-3863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0006932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer