Healthcare Provider Details

I. General information

NPI: 1760895833
Provider Name (Legal Business Name): JACOB KINGSTON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2014
Last Update Date: 06/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2070 NORTHBROOK BLVD
NORTH CHARLESTON SC
29406-9252
US

IV. Provider business mailing address

586 LONE TREE DR
MOUNT PLEASANT SC
29464-8170
US

V. Phone/Fax

Practice location:
  • Phone: 843-824-2183
  • Fax: 843-553-3221
Mailing address:
  • Phone: 843-884-7880
  • Fax: 843-884-6635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7395
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: