Provider Demographics
NPI:1013882778
Name:JACKSON, KAYLA MACKENZIE (PTA)
Entity type:Individual
Prefix:MS
First Name:KAYLA
Middle Name:MACKENZIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 GREENLAWN DR APT 2201
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-0506
Mailing Address - Country:US
Mailing Address - Phone:803-477-8663
Mailing Address - Fax:
Practice Address - Street 1:600 GREENLAWN DR APT 2201
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-0506
Practice Address - Country:US
Practice Address - Phone:803-477-8663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-10
Last Update Date:2025-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPTA.6931225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant