Provider Demographics
NPI:1174291314
Name:KANIKNUNT, JESSADA
Entity Type:Individual
Prefix:
First Name:JESSADA
Middle Name:
Last Name:KANIKNUNT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3041 DREWSKY LN UNIT 101
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-0106
Mailing Address - Country:US
Mailing Address - Phone:803-370-5117
Mailing Address - Fax:
Practice Address - Street 1:3041 DREWSKY LN UNIT 101
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-0106
Practice Address - Country:US
Practice Address - Phone:803-370-5117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2712225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist