Healthcare Provider Details

I. General information

NPI: 1841439304
Provider Name (Legal Business Name): JERED MICHAEL HULL DC, ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2009
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 BLUE SPRINGS RD NW STE 100
KENNESAW GA
30144-1079
US

IV. Provider business mailing address

3400 BLUE SPRINGS RD NW STE 100
KENNESAW GA
30144-1079
US

V. Phone/Fax

Practice location:
  • Phone: 678-707-9002
  • Fax:
Mailing address:
  • Phone: 678-707-9002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001496
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR009034
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: