Healthcare Provider Details

I. General information

NPI: 1508422726
Provider Name (Legal Business Name): JERRUROD PAUL JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 REDDING RD NE
BROOKHAVEN GA
30319-2905
US

IV. Provider business mailing address

2611 REDDING RD NE
BROOKHAVEN GA
30319-2905
US

V. Phone/Fax

Practice location:
  • Phone: 770-882-7091
  • Fax:
Mailing address:
  • Phone: 770-882-7091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC014551
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-85867
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number19-85867
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: