Provider Demographics
NPI:1508243817
Name:FARGASON, JEFFREY
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:FARGASON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 N INDIAN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-2245
Mailing Address - Country:US
Mailing Address - Phone:404-299-1141
Mailing Address - Fax:404-299-8195
Practice Address - Street 1:917 N INDIAN CREEK DR
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:GA
Practice Address - Zip Code:30021-2245
Practice Address - Country:US
Practice Address - Phone:404-299-1141
Practice Address - Fax:404-299-8195
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAHADS000445237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist