MEDICARE: KELLEY JORDAN PUCKETT PT

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	8745	SC
2	225100000X	Physical Therapist	10118	MN

General Provider Information

NPI Number	:	1619343589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEY JORDAN PUCKETT PT

Provider Business Mailing Address
First Line	:	PO BOX 1590
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29071-1590
Country	:	US
Telephone Number	:	803-358-9400
Fax Number	:	803-358-9898

Provider Business Practice Location Address
First Line	:	364 LONGS POND RD STE H
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29073-7942
Country	:	US
Telephone Number	:	803-358-9400
Fax Number	:	803-358-9898

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

Provider Enumeration Date	:	08/14/2015
Last Update Date	:	07/21/2022

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