Provider Demographics
NPI:1992474894
Name:KOHOUT, JERRY JR
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:KOHOUT
Suffix:JR
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 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:570-550-0168
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:2024 OLDE REGENT WAY STE 130
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-4250
Practice Address - Country:US
Practice Address - Phone:910-302-3330
Practice Address - Fax:910-213-3575
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT029822225100000X
NCP22811225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist