Provider Demographics
NPI:1316536063
Name:THACKER, KRISTEN LEIGH
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LEIGH
Last Name:THACKER
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 1:117 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-1403
Mailing Address - Country:US
Mailing Address - Phone:740-237-4981
Mailing Address - Fax:
Practice Address - Street 1:117 N 4TH ST
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-1403
Practice Address - Country:US
Practice Address - Phone:740-237-4981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.162430101YA0400X
OHCDCA.174239101YA0400X
OHRN.482139163WP0809X, 163WA0400X
CMS171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRN.482139OtherOHIO NURSING
OH0430382Medicaid