MEDICARE: JESSICA KNUTELSKY PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	P22904	NC
2	225100000X	Physical Therapist	12268	SC

General Provider Information

NPI Number	:	1538922505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA KNUTELSKY PT, DPT

Provider Business Mailing Address
First Line	:	PO BOX 412066
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02241-2066
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8811 CHARLOTTE HWY STE 101
Second Line	:
City	:	INDIAN LAND
State	:	SC
Zip	:	29707-7901
Country	:	US
Telephone Number	:	803-973-4183
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2024
Last Update Date	:	03/01/2024

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