Provider Demographics
NPI:1417502998
Name:JACKSON, CHRISTOPHER ROBERT
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:ROBERT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 MIDLAND ST
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-5881
Mailing Address - Country:US
Mailing Address - Phone:907-385-5733
Mailing Address - Fax:
Practice Address - Street 1:1502 LIATRIS LN
Practice Address - Street 2:
Practice Address - City:NORTH POLE
Practice Address - State:AK
Practice Address - Zip Code:99705-5082
Practice Address - Country:US
Practice Address - Phone:907-385-5733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK523381322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children