Provider Demographics
NPI:1861597908
Name:JACKSON, KYLE (PT)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:
Last Name:JACKSON
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:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-0010
Mailing Address - Country:US
Mailing Address - Phone:707-837-7980
Mailing Address - Fax:707-837-7983
Practice Address - Street 1:1310 CASA GRANDE RD
Practice Address - Street 2:SUITE B
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-5603
Practice Address - Country:US
Practice Address - Phone:707-782-0921
Practice Address - Fax:707-782-0926
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27666225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ231187OtherMEDICARE GRP ID#
CAZZZ00793ZOtherBLUE SHIELD PROV GRP #
CAZZZ231187OtherMEDICARE GRP ID#
CAZZZ00793ZOtherBLUE SHIELD PROV GRP #