Provider Demographics
NPI:1235477571
Name:PEAL, JASON ALLEN (CSA)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:ALLEN
Last Name:PEAL
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 CREEK RUN PL
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:GA
Mailing Address - Zip Code:30179-5435
Mailing Address - Country:US
Mailing Address - Phone:678-458-7631
Mailing Address - Fax:
Practice Address - Street 1:150 CLINIC AVE
Practice Address - Street 2:101
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4401
Practice Address - Country:US
Practice Address - Phone:770-834-0873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3293246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant