Provider Demographics
NPI:1427364058
Name:JACKSON, KRISTI
Entity Type:Individual
Prefix:
First Name:KRISTI
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 1:115 ROCKWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-9415
Mailing Address - Country:US
Mailing Address - Phone:606-436-5761
Mailing Address - Fax:606-436-5797
Practice Address - Street 1:3367 HWY 119 N
Practice Address - Street 2:
Practice Address - City:MAYKING
Practice Address - State:KY
Practice Address - Zip Code:41837
Practice Address - Country:US
Practice Address - Phone:606-633-4439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0990101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)