Active NPI
Kelli Tracy Jackman, MPT
- Pediatric Physical Therapist
- San Leandro, CA
National Provider Identifier
1750698114
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Physical Therapist
- License
- PT 28294
- Practice address
- 981 Dowling Blvd
San Leandro, CA 94577-2125 - Phone
- (510) 638-9618
- NPI assigned
- Sep 8, 2010
- 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 |
|---|---|---|---|---|
| Pediatric Physical Therapist | 2251P0200X | PT 28294 | CA | Primary |
Addresses
Primary practice location
981 Dowling Blvd
San Leandro, CA 94577-2125
Mailing address
981 Dowling Blvd
San Leandro, CA 94577-2125
Phone (510) 638-9618
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 |
|---|---|---|---|
| PT 28294 | CA | MD | Pediatric Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1283904000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1283904000000",
"number": "1750698114",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "981 DOWLING BLVD",
"city": "SAN LEANDRO",
"state": "CA",
"postal_code": "945772125",
"telephone_number": "510-638-9618"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "981 DOWLING BLVD",
"city": "SAN LEANDRO",
"state": "CA",
"postal_code": "945772125",
"telephone_number": "510-638-9618"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKMAN",
"first_name": "KELLI",
"middle_name": "TRACY",
"credential": "MPT",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2010-09-08",
"last_updated": "2010-09-08",
"status": "A"
},
"taxonomies": [
{
"code": "2251P0200X",
"taxonomy_group": "",
"desc": "Physical Therapist, Pediatrics",
"state": "CA",
"license": "PT 28294",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Leandro, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 8, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.