Healthcare Provider Details

I. General information

NPI: 1619343589
Provider Name (Legal Business Name): KELLEY JORDAN PUCKETT PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

364 LONGS POND RD STE H
LEXINGTON SC
29073-7942
US

IV. Provider business mailing address

PO BOX 1590
LEXINGTON SC
29071-1590
US

V. Phone/Fax

Practice location:
  • Phone: 803-358-9400
  • Fax: 803-358-9898
Mailing address:
  • Phone: 803-358-9400
  • Fax: 803-358-9898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8745
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10118
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: