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General NPI Number Information
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NPI Number | 1689272684
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Entity Type | Individual
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Provider Name | JESSICA CUSHMAN DPT
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Gender | Female
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Dates
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Enumeration Date | 10/12/2020
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Last Update Date | 11/04/2020
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Provider Practice Location Address
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Address Line | 4024 LAWRENCEVILLE HWY NW STE 19
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City | LILBURN
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State | GA
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Zip | 30047-2805
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Country | US
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Telephone | 770-931-8686
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Fax |
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Provider Business Mailing Address
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Address Line | 1454 W LAKE PL
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City | GAINESVILLE
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State | GA
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Zip | 30501-1554
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Country | US
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Telephone | 678-294-0928
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT002969
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT014935
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License Number State | GA
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