Basic Information
| Provider Information | |||||||||
| NPI: | 1306591771 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLIVERSON | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | ALAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4263 WINSLOW HILL CT | ||||||||
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| City: | SUWANEE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300243766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013620498 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2505 NEWPOINT PKWY | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300436003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782577078 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2022 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT004058 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.