Provider Demographics
NPI:1629722327
Name:LEA, JAMIL R
Entity Type:Individual
Prefix:MR
First Name:JAMIL
Middle Name:R
Last Name:LEA
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 1:289 BRYSON LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-5920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:289 BRYSON LAKE CIR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-5920
Practice Address - Country:US
Practice Address - Phone:678-683-5506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA112070500892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty