Healthcare Provider Details

I. General information

NPI: 1326870775
Provider Name (Legal Business Name): MEYENDO JASON SCOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2024
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W PEACHTREE ST NW STE 2300
ATLANTA GA
30309-3453
US

IV. Provider business mailing address

1201 W PEACHTREE ST NW STE 2300
ATLANTA GA
30309-3453
US

V. Phone/Fax

Practice location:
  • Phone: 470-569-2158
  • Fax:
Mailing address:
  • Phone: 470-569-2158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP013168
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: