Provider Demographics
NPI:1235616863
Name:JACKSON, KRISTINA (LPCC)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3606 55TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3310
Mailing Address - Country:US
Mailing Address - Phone:612-599-5471
Mailing Address - Fax:
Practice Address - Street 1:762 TRANSFER RD STE 21
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1489
Practice Address - Country:US
Practice Address - Phone:763-789-4895
Practice Address - Fax:763-789-4798
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01611101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty