Healthcare Provider Details

I. General information

NPI: 1982460077
Provider Name (Legal Business Name): ORIN SETH JENCKES RKT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FREEDOM WAY
AUGUSTA GA
30904-6285
US

IV. Provider business mailing address

3170 SKINNER MILL RD APT Q8
AUGUSTA GA
30909-5027
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-0188
  • Fax:
Mailing address:
  • Phone: 228-223-8673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number2165
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: