Provider Demographics
NPI:1720435886
Name:KIRKLAND, JASON ALLEN (PTA)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:ALLEN
Last Name:KIRKLAND
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:MR
Other - First Name:JASON
Other - Middle Name:ALLEN
Other - Last Name:KIRKLAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:2993 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3421
Mailing Address - Country:US
Mailing Address - Phone:803-939-0026
Mailing Address - Fax:
Practice Address - Street 1:2993 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3421
Practice Address - Country:US
Practice Address - Phone:803-939-0026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3523225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant