Provider Demographics
NPI:1841470473
Name:LUKE, JARED M (MED, ATC, LAT)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:M
Last Name:LUKE
Suffix:
Gender:M
Credentials:MED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 RALEIGH WAY
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-7020
Mailing Address - Country:US
Mailing Address - Phone:678-787-9291
Mailing Address - Fax:
Practice Address - Street 1:256 RALEIGH WAY
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-7020
Practice Address - Country:US
Practice Address - Phone:678-787-9291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0014432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer