Provider Demographics
NPI:1487689659
Name:KELLEY, JONATHAN C (PT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:C
Last Name:KELLEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 SAVANNAH HWY
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7207
Mailing Address - Country:US
Mailing Address - Phone:843-766-2121
Mailing Address - Fax:843-766-8644
Practice Address - Street 1:445 SAVANNAH HWY
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407
Practice Address - Country:US
Practice Address - Phone:843-766-2121
Practice Address - Fax:843-766-8644
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3950225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1300Medicaid
SCTH1300Medicaid