Provider Demographics
NPI:1720644784
Name:IRWIN, JEFFREY (LMT, CSCS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:IRWIN
Suffix:
Gender:M
Credentials:LMT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 TIDAL VIEW LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-8420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1140 TIDAL VIEW LN
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-8420
Practice Address - Country:US
Practice Address - Phone:843-810-5049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11672224Y00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist