Provider Demographics
NPI:1871803577
Name:MCMICHAEL, JENNIFER BLAIR (DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BLAIR
Last Name:MCMICHAEL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2089 TERON TRACE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019
Mailing Address - Country:US
Mailing Address - Phone:770-904-6009
Mailing Address - Fax:770-904-2357
Practice Address - Street 1:2089 TERON TRACE
Practice Address - Street 2:SUITE 120
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019
Practice Address - Country:US
Practice Address - Phone:770-904-6009
Practice Address - Fax:770-904-2357
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010117225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist