Active NPI
Chevis M Jackson
- Physical Therapy Assistant
- Cumming, GA
National Provider Identifier
1205413507
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapy Assistant
- License
- PTA003382
- Practice address
- 125 Samaritan Dr
Cumming, GA 30040-2354 - Phone
- (770) 889-1644
- NPI assigned
- Mar 24, 2021
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapy Assistant | 225200000X | PTA003382 | GA | Primary |
Addresses
Primary practice location
125 Samaritan Dr
Cumming, GA 30040-2354
Mailing address
1335 Oakshyre PL
Lawrenceville, GA 30043-6435
Phone (504) 912-5169
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PTA003382 | GA | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1616544000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1616544000000",
"number": "1205413507",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1335 OAKSHYRE PL",
"city": "LAWRENCEVILLE",
"state": "GA",
"postal_code": "300436435",
"telephone_number": "504-912-5169"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "125 SAMARITAN DR",
"city": "CUMMING",
"state": "GA",
"postal_code": "300402354",
"telephone_number": "770-889-1644"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "CHEVIS",
"middle_name": "M",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2021-03-24",
"last_updated": "2021-03-24",
"certification_date": "2021-03-24",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "GA",
"license": "PTA003382",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Cumming, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 24, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.