Healthcare Provider Details

I. General information

NPI: 1508523986
Provider Name (Legal Business Name): JESSICA LAUREN KUCHTA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2021
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 MILLWOOD AVE
COLUMBIA SC
29205-1261
US

IV. Provider business mailing address

2829 MILLWOOD AVE
COLUMBIA SC
29205-1261
US

V. Phone/Fax

Practice location:
  • Phone: 803-851-3506
  • Fax: 803-619-9551
Mailing address:
  • Phone: 803-851-3506
  • Fax: 803-619-9551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11011
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: