Healthcare Provider Details

I. General information

NPI: 1063846855
Provider Name (Legal Business Name): JENERIA NYOSHA TAYLOR PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENERIA TAPP

II. Dates (important events)

Enumeration Date: 08/28/2013
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1495 NORTHSIDE DR NW STE A
ATLANTA GA
30318-4200
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 470-823-2030
  • Fax: 470-823-2031
Mailing address:
  • Phone: 586-350-2644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT011136
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: