Provider Demographics
NPI:1306057146
Name:KAKOURIS, JIMMY (PT, DPT CSCS)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:KAKOURIS
Suffix:
Gender:M
Credentials:PT, DPT CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 BARRY RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-1136
Mailing Address - Country:US
Mailing Address - Phone:239-209-0320
Mailing Address - Fax:239-209-0320
Practice Address - Street 1:81 SHREWSBURY ST STE 1
Practice Address - Street 2:
Practice Address - City:BOYLSTON
Practice Address - State:MA
Practice Address - Zip Code:01505-1701
Practice Address - Country:US
Practice Address - Phone:774-614-1322
Practice Address - Fax:774-614-1171
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18231225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA18231OtherSTATE LICENSE
FLPT22262OtherSTATE LICENSE