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General NPI Number Information
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NPI Number | 1265212294
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Entity Type | Individual
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Provider Name | JEREMIAH PHILOGENE
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Gender | Male
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Dates
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Enumeration Date | 10/05/2023
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Last Update Date | 10/05/2023
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Provider Practice Location Address
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Address Line | 404 KING SPRINGS VILLAGE PKWY SE
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City | SMYRNA
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State | GA
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Zip | 30082-4240
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Country | US
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Telephone | 770-432-4444
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Fax |
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Provider Business Mailing Address
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Address Line | 5091 LINDA VISTA DR SW
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City | MABLETON
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State | GA
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Zip | 30126-2013
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Country | US
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Telephone | 239-273-1688
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 002869
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License Number State | GA
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