Provider Demographics
NPI:1598419848
Name:KOJIMA, JACKSON KISUKE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:KISUKE
Last Name:KOJIMA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 GROVE RD STE C
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4630
Mailing Address - Country:US
Mailing Address - Phone:864-233-5128
Mailing Address - Fax:
Practice Address - Street 1:30 RUSHMORE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-1255
Practice Address - Country:US
Practice Address - Phone:864-233-5128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist