Provider Demographics
NPI:1518024991
Name:PRESTON, JON MICHAEL (MSPT)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:MICHAEL
Last Name:PRESTON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2557 COLLINS PORT CV
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-2787
Mailing Address - Country:US
Mailing Address - Phone:770-232-7100
Mailing Address - Fax:770-232-7198
Practice Address - Street 1:1810 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-8180
Practice Address - Country:US
Practice Address - Phone:770-232-7100
Practice Address - Fax:770-232-7198
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006667225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7480721OtherAETNA PPO POS PIN
GA9406564OtherPHCS PIN
GA52068657-004OtherBCBSGA PROVIDER NUMBER
GA65BBDGGMedicare PIN
GAQ51555Medicare UPIN
GAGRP7396Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER