Provider Demographics
NPI:1992042360
Name:KOLLER, JESSICA ALEXIS (ATC)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:ALEXIS
Last Name:KOLLER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SPENCER PL
Mailing Address - Street 2:APT 913
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033-3980
Mailing Address - Country:US
Mailing Address - Phone:203-470-1558
Mailing Address - Fax:
Practice Address - Street 1:2 MEDICAL PARK RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6808
Practice Address - Country:US
Practice Address - Phone:203-470-1558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-05
Last Update Date:2013-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13392081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine