Provider Demographics
NPI:1699582205
Name:KIKKERT, JONATAN ANTHONIE
Entity type:Individual
Prefix:
First Name:JONATAN
Middle Name:ANTHONIE
Last Name:KIKKERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1544 MARTINGALE WAY
Mailing Address - Street 2:
Mailing Address - City:ROEBUCK
Mailing Address - State:SC
Mailing Address - Zip Code:29376-2798
Mailing Address - Country:US
Mailing Address - Phone:615-540-8343
Mailing Address - Fax:
Practice Address - Street 1:351 OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-2537
Practice Address - Country:US
Practice Address - Phone:864-595-4225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC126012251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics