Provider Demographics
NPI:1194470443
Name:JACKSON, CRISTA
Entity Type:Individual
Prefix:
First Name:CRISTA
Middle Name:
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 1:1234 S POWER RD STE 252
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-3700
Mailing Address - Country:US
Mailing Address - Phone:602-675-6185
Mailing Address - Fax:
Practice Address - Street 1:1234 S POWER RD STE 252
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3700
Practice Address - Country:US
Practice Address - Phone:602-675-6185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health