Provider Demographics
NPI:1457330227
Name:JACKSON, KRISTA L (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:L
Other - Last Name:WELCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 406
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-0406
Mailing Address - Country:US
Mailing Address - Phone:606-889-6185
Mailing Address - Fax:606-889-6186
Practice Address - Street 1:5000 KY ROUTE 321
Practice Address - Street 2:SUITE 2162
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-9113
Practice Address - Country:US
Practice Address - Phone:606-889-6185
Practice Address - Fax:606-889-6186
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA 586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95003141Medicaid
KY000000520426OtherBCBS
P00290504OtherRAILROAD
KY000000520426OtherBCBS
P00290504OtherRAILROAD