Individual
JACKSON KEITH MIZE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
ATC
Contact information
Practice address
590 COBB AVENUE MD #0201, KENNESAW, GA 30144
(470) 578-2786
Mailing address
3091 COBB PKWY NW APT 1334, KENNESAW, GA 30152-8000
(256) 509-5364
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
AT003505
GA
Other
Enumeration date
07/10/2023
Last updated
07/10/2023
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