1245429984 NPI number — SKINNER AND ASSOCIATES P.C.

Table of content: JASON RUSSELL ROE PT,DPT (NPI 1376799254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245429984 NPI number — SKINNER AND ASSOCIATES P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SKINNER AND ASSOCIATES P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245429984
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
66 FARMER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWNAN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30263-1437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-253-3512
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
66 FARMER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWNAN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30263-1437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-253-3512
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SKINNER
Authorized Official First Name:
WALTER
Authorized Official Middle Name:
WINSTON
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
770-253-3512

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  1295 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: IPO 40380 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: R-12544 . This is a "UPIN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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