Provider Demographics
NPI:1972178440
Name:COSBY, JAMAL R
Entity type:Individual
Prefix:
First Name:JAMAL
Middle Name:R
Last Name:COSBY
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 1:3533 MAIN ST APT 3
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30337-2600
Mailing Address - Country:US
Mailing Address - Phone:404-671-5540
Mailing Address - Fax:
Practice Address - Street 1:3533 MAIN ST APT 3
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30337-2600
Practice Address - Country:US
Practice Address - Phone:404-671-5540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor