Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT014802 | GA |
N | 2251X0800X | Physical Therapist - Orthopedic | PT014802 | GA |
NPI | 1013527811 |
---|---|
Provider Name | Jackson James Cervi |
First Address | Atlanta, GA 30309-1527 |
Second Address | Atlanta, GA 30309-1476 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/08/2020 |
Last Update Date | 06/08/2020 |