Provider Demographics
NPI:1215157169
Name:KING, JASON (PHD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1775 THE EXCHANGE SE
Mailing Address - Street 2:STE 327
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-2016
Mailing Address - Country:US
Mailing Address - Phone:770-933-4130
Mailing Address - Fax:770-933-4130
Practice Address - Street 1:1775 THE EXCHANGE SE
Practice Address - Street 2:STE 327
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-2016
Practice Address - Country:US
Practice Address - Phone:770-933-4130
Practice Address - Fax:770-933-4130
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002888103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ58820Medicare UPIN
GA68BBGRPMedicare ID - Type Unspecified