Provider Demographics
NPI:1609137140
Name:COURSEAULT, JAESON K
Entity Type:Individual
Prefix:
First Name:JAESON
Middle Name:K
Last Name:COURSEAULT
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 1:2994 E RAMBLE LN
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-1120
Mailing Address - Country:US
Mailing Address - Phone:404-500-7224
Mailing Address - Fax:
Practice Address - Street 1:3939 LAVISTA RD
Practice Address - Street 2:STE. E274
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345
Practice Address - Country:US
Practice Address - Phone:404-500-7224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ5992207QS0010X
GA86941207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine