NPIMap

Individual provider Active NPI

Kim Jackson

  • Community Health Worker
  • San Bernardino, CA
National Provider Identifier
1902257389
Registry record updated Nov 30, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Health WorkerTaxonomy code 172V00000X
Practice address
1481 Windsor Dr
San Bernardino, CA 92404-5416
Phone
(951) 643-2340
NPI assigned
Jun 27, 2016
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Nov 30, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Case Manager/Care Coordinator 171M00000X
Peer Specialist 175T00000X
Community Health Worker 172V00000X Primary

Addresses

Primary practice location

1481 Windsor Dr
San Bernardino, CA 92404-5416

Mailing address

3125 Myers St
Riverside, CA 92503-5527
Phone (951) 358-5862

Other practice location 1

22445 Alessandro Blvd Ste 113-114
Moreno Valley, CA 92553-8358
Phone (951) 788-8812

Other practice location 2

6235 River Crest Dr Ste O
Riverside, CA 92507-0758
Phone (951) 653-7561

Other practice location 3

3125 Myers St
Riverside, CA 92503-5527
Phone (951) 358-5862

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

Practice roles

OrganizationSpecialtyStatusNew patients
Creative Solutions for Kids & Families PastSince Feb 1, 2022 Accepting new patients
Plan-It Life, Inc. PastSince Jun 28, 2020 Accepting new patients
Plan-It Life, Inc. PastSince Jun 28, 2020 Accepting new patients

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1466985600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1701302400000",
    "number": "1902257389",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3125 MYERS ST",
            "city": "RIVERSIDE",
            "state": "CA",
            "postal_code": "925035527",
            "telephone_number": "951-358-5862"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1481 WINDSOR DR",
            "city": "SAN BERNARDINO",
            "state": "CA",
            "postal_code": "924045416",
            "telephone_number": "951-643-2340"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "22445 Alessandro Blvd Ste 113-114",
            "address_purpose": "LOCATION",
            "city": "Moreno Valley",
            "state": "CA",
            "postal_code": "925538358",
            "country_code": "US",
            "telephone_number": "951-788-8812",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "6235 River Crest Dr Ste O",
            "address_purpose": "LOCATION",
            "city": "Riverside",
            "state": "CA",
            "postal_code": "925070758",
            "country_code": "US",
            "telephone_number": "951-653-7561",
            "fax_number": "951-653-7563",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "3125 Myers St",
            "address_purpose": "LOCATION",
            "city": "Riverside",
            "state": "CA",
            "postal_code": "925035527",
            "country_code": "US",
            "telephone_number": "951-358-5862",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "KIM",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2016-06-27",
        "last_updated": "2023-11-30",
        "certification_date": "2023-11-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "171M00000X",
            "taxonomy_group": "",
            "desc": "Case Manager/Care Coordinator",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "175T00000X",
            "taxonomy_group": "",
            "desc": "Peer Specialist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "172V00000X",
            "taxonomy_group": "",
            "desc": "Community Health Worker",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in San Bernardino, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 30, 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.

Verify at the official NPI Registry.