Provider Demographics
NPI:1194480764
Name:MOSBY, JEMICAH
Entity type:Individual
Prefix:
First Name:JEMICAH
Middle Name:
Last Name:MOSBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 SABLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:GA
Mailing Address - Zip Code:30004-8048
Mailing Address - Country:US
Mailing Address - Phone:770-377-7633
Mailing Address - Fax:
Practice Address - Street 1:385 SABLEWOOD DR
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:GA
Practice Address - Zip Code:30004-8048
Practice Address - Country:US
Practice Address - Phone:770-377-7633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004956225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist