Provider Demographics
NPI:1184841728
Name:KAKLEAS, JON MARK (DC, PT)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:MARK
Last Name:KAKLEAS
Suffix:
Gender:M
Credentials:DC, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4380 REDWOOD HIGHWAY, STE. B-6
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903
Mailing Address - Country:US
Mailing Address - Phone:415-499-8469
Mailing Address - Fax:415-499-8645
Practice Address - Street 1:4380 REDWOOD HWY STE B6
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2110
Practice Address - Country:US
Practice Address - Phone:415-499-8469
Practice Address - Fax:415-499-8645
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 23537111N00000X
CAPT 109380225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC 023537Medicare ID - Type UnspecifiedCHIROPRACTOR
CAOPT 109380Medicare ID - Type UnspecifiedPHYSICAL THERAPIST