Provider Demographics
NPI:1306591771
Name:OLIVERSON, JACOB ALAN
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ALAN
Last Name:OLIVERSON
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 1:4263 WINSLOW HILL CT
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-3766
Mailing Address - Country:US
Mailing Address - Phone:801-362-0498
Mailing Address - Fax:
Practice Address - Street 1:2505 NEWPOINT PKWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-6003
Practice Address - Country:US
Practice Address - Phone:678-257-7078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0040582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer