Provider Demographics
NPI:1861659690
Name:SUMMERS, JACQUELINE R (OT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:R
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5635 STONINGTON TRACE PKWY
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-5248
Mailing Address - Country:US
Mailing Address - Phone:770-879-8078
Mailing Address - Fax:
Practice Address - Street 1:1200 LAKE HEARN DR NE
Practice Address - Street 2:SUITE 250
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319-1415
Practice Address - Country:US
Practice Address - Phone:404-943-1070
Practice Address - Fax:404-943-0890
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOY002477225X00000X
GAOT002477225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA028577889OtherDRIVERS LICENSE