Active NPI
Kathlyn Tan Jackson, MT
- Massage Therapist
- Fountain Valley, CA
National Provider Identifier
1205421526
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Massage Therapist
- License
- 39797
- Practice address
- 11770 Warner Ave Ste 123
Fountain Valley, CA 92708-2660 - Phone
- (714) 277-7169
- NPI assigned
- Mar 8, 2021
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Massage Therapist | 225700000X | 39797 | CA | Primary |
Addresses
Primary practice location
11770 Warner Ave Ste 123
Fountain Valley, CA 92708-2660
Mailing address
617 Rosita St
Santa Ana, CA 92703-2553
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Medical Technician
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 39797 | CA | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1615161600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1615161600000",
"number": "1205421526",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "617 ROSITA ST",
"city": "SANTA ANA",
"state": "CA",
"postal_code": "927032553"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "11770 WARNER AVE STE 123",
"city": "FOUNTAIN VALLEY",
"state": "CA",
"postal_code": "927082660",
"telephone_number": "714-277-7169"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "KATHLYN",
"middle_name": "TAN",
"credential": "MT",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2021-03-08",
"last_updated": "2021-03-08",
"certification_date": "2021-03-08",
"status": "A"
},
"taxonomies": [
{
"code": "225700000X",
"taxonomy_group": "",
"desc": "Massage Therapist",
"state": "CA",
"license": "39797",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fountain Valley, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 8, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.