Provider Demographics
NPI:1770574436
Name:THORNHILL, JARED BLAKE (OD)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:BLAKE
Last Name:THORNHILL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2347 LENORA CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3232
Mailing Address - Country:US
Mailing Address - Phone:770-979-2020
Mailing Address - Fax:770-978-3321
Practice Address - Street 1:2347 LENORA CHURCH RD
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3232
Practice Address - Country:US
Practice Address - Phone:770-979-2020
Practice Address - Fax:770-978-3321
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001850152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00899841AMedicaid
GAU82657Medicare UPIN
GA00899841AMedicaid