Basic Information
| Provider Information | |||||||||
| NPI: | 1386861110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STRONG | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2041 MESA VALLEY WAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301066828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709441100 | ||||||||
| FaxNumber: | 7709446469 | ||||||||
| Practice Location | |||||||||
| Address1: | 2041 MESA VALLEY WAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301066828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709441100 | ||||||||
| FaxNumber: | 7709446469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 04/12/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 061001 | GA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 561121199F | 05 | GA | MEDICAID | 561121199C | 05 | GA | MEDICAID | 561121199D | 05 | GA | MEDICAID |