Healthcare Provider Details

I. General information

NPI: 1598419848
Provider Name (Legal Business Name): JACKSON KISUKE KOJIMA PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 RUSHMORE DR
GREENVILLE SC
29615-1255
US

IV. Provider business mailing address

1007 GROVE RD STE C
GREENVILLE SC
29605-4630
US

V. Phone/Fax

Practice location:
  • Phone: 864-233-5128
  • Fax:
Mailing address:
  • Phone: 864-233-5128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: