Provider Demographics
NPI:1578298022
Name:JACK, KADARIUS (DPT)
Entity Type:Individual
Prefix:
First Name:KADARIUS
Middle Name:
Last Name:JACK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 JASMINE LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-4590
Mailing Address - Country:US
Mailing Address - Phone:865-297-7481
Mailing Address - Fax:
Practice Address - Street 1:308 BRYNN MARR RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7023
Practice Address - Country:US
Practice Address - Phone:910-478-9701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist