Provider Demographics
NPI:1164760500
Name:JACKSON, KRISTEN B (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 MEDICAL CENTER DR
Mailing Address - Street 2:DODD HALL 2145
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1229
Mailing Address - Country:US
Mailing Address - Phone:614-293-3830
Mailing Address - Fax:614-293-4870
Practice Address - Street 1:480 MEDICAL CENTER DR
Practice Address - Street 2:DODD HALL 2145
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1229
Practice Address - Country:US
Practice Address - Phone:614-293-3830
Practice Address - Fax:614-293-4870
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation