Provider Demographics
NPI:1053085597
Name:JACKSON, KRISTA SOFIA (MS)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:SOFIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:KRISTA
Other - Middle Name:SOFIA
Other - Last Name:BILLINGY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:410 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-4099
Mailing Address - Country:US
Mailing Address - Phone:224-303-2160
Mailing Address - Fax:
Practice Address - Street 1:410 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-4099
Practice Address - Country:US
Practice Address - Phone:224-303-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-08
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242006552235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist