Healthcare Provider Details

I. General information

NPI: 1457561698
Provider Name (Legal Business Name): JESSICA RAQUEL MILES ATC-L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA RAQUEL DYSART

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SHERWOOD PARK DRIVE, NE STE. 140
GAINESVILLE GA
30501-3426
US

IV. Provider business mailing address

8823 PRODUCTION LN
OOLTEWAH TN
37363-6511
US

V. Phone/Fax

Practice location:
  • Phone: 770-297-7750
  • Fax:
Mailing address:
  • Phone: 423-238-7217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number927
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001878
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: