Provider Demographics
NPI:1083042345
Name:JACKSON, KRISTINA YVETTE
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:YVETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11285 DRAKE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133-5405
Mailing Address - Country:US
Mailing Address - Phone:440-305-2822
Mailing Address - Fax:
Practice Address - Street 1:6548 ROYALTON RD STE 101
Practice Address - Street 2:
Practice Address - City:NORTH ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44133-4976
Practice Address - Country:US
Practice Address - Phone:440-305-2822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-24
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH691-S156FX1800X
OH03151237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician