Provider Demographics
NPI:1487411195
Name:QUEZADA, JOSE
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:QUEZADA
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JOSE
Other - Middle Name:D
Other - Last Name:QUEZADA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:1325 SATELLITE BLVD NW STE 400
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-5299
Mailing Address - Country:US
Mailing Address - Phone:263-678-2633
Mailing Address - Fax:
Practice Address - Street 1:1325 SATELLITE BLVD NW STE 400
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-5299
Practice Address - Country:US
Practice Address - Phone:263-678-2633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-29
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN292069163WP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health