Provider Demographics
NPI:1073656054
Name:WEBER, JEFF (EDD)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:
Last Name:WEBER
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 SUWANEE DAM ROAD
Mailing Address - Street 2:STE. 920
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-8711
Mailing Address - Country:US
Mailing Address - Phone:678-714-9590
Mailing Address - Fax:678-714-4953
Practice Address - Street 1:4411 SUWANEE DAM ROAD
Practice Address - Street 2:STE. 920
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-8711
Practice Address - Country:US
Practice Address - Phone:678-714-9590
Practice Address - Fax:678-714-4953
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2094103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00772054EMedicaid
GA582663314Medicare UPIN
GA00772054EMedicaid