Provider Demographics
NPI:1609105808
Name:MAINOR, JEREMY MARCUS (PTA)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:MARCUS
Last Name:MAINOR
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 1:100 ROBINS WEST PKWY
Mailing Address - Street 2:APT. 718
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-8121
Mailing Address - Country:US
Mailing Address - Phone:478-550-6725
Mailing Address - Fax:
Practice Address - Street 1:3051 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-8536
Practice Address - Country:US
Practice Address - Phone:478-971-2235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-17
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002538172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker