Healthcare Provider Details

I. General information

NPI: 1609137140
Provider Name (Legal Business Name): JAESON K. COURSEAULT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 09/13/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 LAVISTA RD STE. E274
ATLANTA GA
30345
US

IV. Provider business mailing address

2994 E RAMBLE LN
DECATUR GA
30033-1120
US

V. Phone/Fax

Practice location:
  • Phone: 404-500-7224
  • Fax:
Mailing address:
  • Phone: 404-500-7224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberQ5992
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number86941
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: