Provider Demographics
NPI:1790324101
Name:PARHAM, JAKE (OTR/L)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:PARHAM
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 MEDICAL BLVD
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-5083
Mailing Address - Country:US
Mailing Address - Phone:770-474-9514
Mailing Address - Fax:
Practice Address - Street 1:125 MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5083
Practice Address - Country:US
Practice Address - Phone:770-474-9514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GAOT008793225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician