Provider Demographics
NPI:1225784259
Name:NICHOLS, JEREMIAH TATE (PTA, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:TATE
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:PTA, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4384 EARNEY RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-5600
Mailing Address - Country:US
Mailing Address - Phone:828-851-1639
Mailing Address - Fax:
Practice Address - Street 1:147 REINHARDT COLLEGE PKWY STE 9
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5295
Practice Address - Country:US
Practice Address - Phone:770-345-3057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0022232255A2300X
GAPTA004362225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer