Provider Demographics
NPI:1497315238
Name:FOUTS, JEREMY (EDS, MS, ATC)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:
Last Name:FOUTS
Suffix:
Gender:M
Credentials:EDS, MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535-5252
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1021 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-5252
Practice Address - Country:US
Practice Address - Phone:706-776-0116
Practice Address - Fax:706-778-0701
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0025872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer