Provider Demographics
NPI:1760895833
Name:KINGSTON, JACOB (DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KINGSTON
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 1:586 LONE TREE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-8170
Mailing Address - Country:US
Mailing Address - Phone:843-884-7880
Mailing Address - Fax:843-884-6635
Practice Address - Street 1:2070 NORTHBROOK BLVD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9252
Practice Address - Country:US
Practice Address - Phone:843-824-2183
Practice Address - Fax:843-553-3221
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7395225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8702Medicare PIN