Provider Demographics
NPI:1265212294
Name:PHILOGENE, JEREMIAH
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:PHILOGENE
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 1:5091 LINDA VISTA DR SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-2013
Mailing Address - Country:US
Mailing Address - Phone:239-273-1688
Mailing Address - Fax:
Practice Address - Street 1:404 KING SPRINGS VILLAGE PKWY SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-4240
Practice Address - Country:US
Practice Address - Phone:770-432-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002869224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant