Individual
JEREMIAH TATE NICHOLS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PTA, LAT, ATC
Contact information
Practice address
147 REINHARDT COLLEGE PKWY STE 9, CANTON, GA 30114-5295
(770) 345-3057
Mailing address
4384 EARNEY RD, WOODSTOCK, GA 30188-5600
(828) 851-1639
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
PTA004362
GA
2255A2300X
Athletic Trainer
AT002223
GA
Other
Enumeration date
02/28/2022
Last updated
02/28/2022
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