Healthcare Provider Details

I. General information

NPI: 1881372829
Provider Name (Legal Business Name): JACKSON KEITH MIZE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 COBB AVENUE MD #0201
KENNESAW GA
30144
US

IV. Provider business mailing address

3091 COBB PKWY NW APT 1334
KENNESAW GA
30152-8000
US

V. Phone/Fax

Practice location:
  • Phone: 470-578-2786
  • Fax:
Mailing address:
  • Phone: 256-509-5364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT003505
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: