Provider Demographics
NPI:1255004552
Name:JEROME, STEFAN ALEXANDER (PTA)
Entity Type:Individual
Prefix:
First Name:STEFAN
Middle Name:ALEXANDER
Last Name:JEROME
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 UPPER RIVERDALE RD STE B10
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-1071
Mailing Address - Country:US
Mailing Address - Phone:770-907-5743
Mailing Address - Fax:
Practice Address - Street 1:335 UPPER RIVERDALE RD STE B10
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1071
Practice Address - Country:US
Practice Address - Phone:770-907-5743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-01
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA004704225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant