Provider Demographics
NPI:1679825822
Name:KING, JACKIE (R,PT)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:R,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3712 EXECUTIVE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-5095
Mailing Address - Country:US
Mailing Address - Phone:706-869-7495
Mailing Address - Fax:706-869-7497
Practice Address - Street 1:3712 EXECUTIVE CENTER DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-5095
Practice Address - Country:US
Practice Address - Phone:706-869-7495
Practice Address - Fax:706-869-7497
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT001809225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist