Healthcare Provider Details

I. General information

NPI: 1700980224
Provider Name (Legal Business Name): JASON A. KING, PH.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 LAKE PARK DR SE STE 110
SMYRNA GA
30080-8979
US

IV. Provider business mailing address

2400 LAKE PARK DR SE STE 110
SMYRNA GA
30080-8979
US

V. Phone/Fax

Practice location:
  • Phone: 770-933-4130
  • Fax: 770-933-4135
Mailing address:
  • Phone: 770-933-4130
  • Fax: 770-933-4135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY002888
License Number StateGA

VIII. Authorized Official

Name: JASON ANTHONY KING
Title or Position: PRESIDENT
Credential: PHD
Phone: 770-933-4130