Provider Demographics
NPI:1811762966
Name:LONG, JIMMY TAFT (PT)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:TAFT
Last Name:LONG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 BELTLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-2063
Mailing Address - Country:US
Mailing Address - Phone:803-513-5397
Mailing Address - Fax:
Practice Address - Street 1:1330 KINARD ST
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-3038
Practice Address - Country:US
Practice Address - Phone:803-405-1585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3691225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist