Provider Demographics
NPI:1992812135
Name:ACKERMAN, KENNETH JOHN
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOHN
Last Name:ACKERMAN
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 1:9471 THREE RIVERS RD STE D
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4230
Mailing Address - Country:US
Mailing Address - Phone:228-822-9066
Mailing Address - Fax:228-822-9722
Practice Address - Street 1:9471 THREE RIVERS RD STE D
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4230
Practice Address - Country:US
Practice Address - Phone:228-822-9066
Practice Address - Fax:228-822-9722
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2298225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09432550Medicaid
MS650000254Medicare PIN