Provider Demographics
NPI:1013276765
Name:CHEATHAM-TERRY, JACQUELYN (DO)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:CHEATHAM-TERRY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 COBB PARKWAY NORTH NW STE 201A
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-4182
Mailing Address - Country:US
Mailing Address - Phone:770-974-4655
Mailing Address - Fax:770-974-1970
Practice Address - Street 1:4550 COBB PARKWAY NORTH NW STE 201A
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4182
Practice Address - Country:US
Practice Address - Phone:770-974-4655
Practice Address - Fax:770-974-1970
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA71325207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003146788EMedicaid
GA202I089703Medicare PIN