Provider Demographics
NPI:1922248244
Name:JEAN-LOUIS, GUSTAVE
Entity Type:Individual
Prefix:MR
First Name:GUSTAVE
Middle Name:
Last Name:JEAN-LOUIS
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 1:965 HAVENSTONE WALK
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-9706
Mailing Address - Country:US
Mailing Address - Phone:770-736-6383
Mailing Address - Fax:
Practice Address - Street 1:965 HAVENSTONE WALK
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-9706
Practice Address - Country:US
Practice Address - Phone:770-736-6383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-26
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002345225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant