Active NPI
Kenneth Wayne Waldburg Jr.
- Massage Therapist
- Jacksonville, FL
National Provider Identifier
1316712698
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Massage Therapist
- License
- MA62122
- Practice address
- 4629 Gerber CT
Jacksonville, FL 32210-1411 - Phone
- (904) 790-3671
- NPI assigned
- Nov 16, 2023
- Sex
- Male
- 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 | MA62122 | FL | Primary |
Addresses
Primary practice location
4629 Gerber CT
Jacksonville, FL 32210-1411
Mailing address
4629 Gerber CT
Jacksonville, FL 32210-1411
Phone (904) 790-3671
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
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MA62122 | FL | MD | Massage Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1700092800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1700092800000",
"number": "1316712698",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4629 GERBER CT",
"city": "JACKSONVILLE",
"state": "FL",
"postal_code": "322101411",
"telephone_number": "904-790-3671"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4629 GERBER CT",
"city": "JACKSONVILLE",
"state": "FL",
"postal_code": "322101411",
"telephone_number": "904-790-3671"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALDBURG",
"first_name": "KENNETH",
"middle_name": "WAYNE",
"name_prefix": "Mr.",
"name_suffix": "Jr.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2023-11-16",
"last_updated": "2023-11-16",
"certification_date": "2023-11-16",
"status": "A"
},
"taxonomies": [
{
"code": "225700000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Massage Therapist",
"state": "FL",
"license": "MA62122",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Jacksonville, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 16, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.