Active NPI
Kellene Shey Jackson, COTA
- Occupational Therapy Assistant
- Maitland, FL
National Provider Identifier
1770616138
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Occupational Therapy Assistant
- License
- 9463
- Practice address
- 1301 W Maitland Blvd
Maitland, FL 32751-4338 - Phone
- (407) 645-0034
- NPI assigned
- Mar 14, 2007
- 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 |
|---|---|---|---|---|
| Occupational Therapy Assistant | 224Z00000X | 9463 | FL | Primary |
Addresses
Primary practice location
1301 W Maitland Blvd
Maitland, FL 32751-4338
Mailing address
315 Howard Blvd
Longwood, FL 32750-4616
Phone (407) 402-3203
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 |
|---|---|---|---|
| 9463 | FL | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1173830400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1263081600000",
"number": "1770616138",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "315 HOWARD BLVD",
"city": "LONGWOOD",
"state": "FL",
"postal_code": "327504616",
"telephone_number": "407-402-3203"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1301 W MAITLAND BLVD",
"city": "MAITLAND",
"state": "FL",
"postal_code": "327514338",
"telephone_number": "407-645-0034"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "KELLENE",
"middle_name": "SHEY",
"credential": "COTA",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-03-14",
"last_updated": "2010-01-10",
"status": "A"
},
"taxonomies": [
{
"code": "224Z00000X",
"taxonomy_group": "",
"desc": "Occupational Therapy Assistant",
"state": "FL",
"license": "9463",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Maitland, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 10, 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.