Healthcare Provider Details

I. General information

NPI: 1831964980
Provider Name (Legal Business Name): JEB KINCANNON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 11/20/2023
Certification Date: 11/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 CRILL AVE BLDG 3
PALATKA FL
32177-9231
US

IV. Provider business mailing address

PO BOX 1473
ST AUGUSTINE FL
32085-1473
US

V. Phone/Fax

Practice location:
  • Phone: 386-325-1119
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: