Jeremiah Tate Nichols, PTA, LAT, ATC

Primary specialty

Physical Therapy AssistantTaxonomy code 225200000X

License

PTA004362 Issued in GA

Practice address

147 Reinhardt College Pkwy Ste 9
Canton, GA 30114-5295

Phone

(770) 345-3057

NPI assigned

Feb 28, 2022

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1646006400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1646006400000",
    "number": "1225784259",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4384 EARNEY RD",
            "city": "WOODSTOCK",
            "state": "GA",
            "postal_code": "301885600",
            "telephone_number": "828-851-1639"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "147 REINHARDT COLLEGE PKWY STE 9",
            "city": "CANTON",
            "state": "GA",
            "postal_code": "301145295",
            "telephone_number": "770-345-3057"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "NICHOLS",
        "first_name": "JEREMIAH",
        "middle_name": "TATE",
        "credential": "PTA, LAT, ATC",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2022-02-28",
        "last_updated": "2022-02-28",
        "certification_date": "2022-02-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2255A2300X",
            "taxonomy_group": "",
            "desc": "Specialist/Technologist, Athletic Trainer",
            "state": "GA",
            "license": "AT002223",
            "primary": false
        },
        {
            "code": "225200000X",
            "taxonomy_group": "",
            "desc": "Physical Therapy Assistant",
            "state": "GA",
            "license": "PTA004362",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "jeremiah.nichols@georgiapt.com",
            "affiliation": "Y",
            "affiliationName": "Georgia Physical Therapy & Sports Medicine Center",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "147 Reinhardt College Pkwy Ste 9",
            "city": "Canton",
            "state": "GA",
            "country_code": "US",
            "postal_code": "301145295",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Physical Therapy Assistant in Canton, GA
• Providers in Canton, GA by specialty
• Physical Therapy Assistant in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 28, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.