Healthcare Provider Details

I. General information

NPI: 1992042360
Provider Name (Legal Business Name): JESSICA ALEXIS KOLLER ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2013
Last Update Date: 01/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MEDICAL PARK RD
COLUMBIA SC
29203-6808
US

IV. Provider business mailing address

215 SPENCER PL APT 913
CAYCE SC
29033-3980
US

V. Phone/Fax

Practice location:
  • Phone: 203-470-1558
  • Fax:
Mailing address:
  • Phone: 203-470-1558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number1339
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: