Healthcare Provider Details

I. General information

NPI: 1962108274
Provider Name (Legal Business Name): JESSICA SUSANNE EADY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 OLD NORCROSS RD STE 100
LAWRENCEVILLE GA
30046-3390
US

IV. Provider business mailing address

1216 WESLEY ST
OXFORD GA
30054-2246
US

V. Phone/Fax

Practice location:
  • Phone: 678-377-2833
  • Fax: 678-377-2882
Mailing address:
  • Phone: 404-915-6923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT008731
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: