Provider Demographics
NPI:1467690487
Name:JACKSON, KRISTINE (FNP)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 SANDHILL DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-5805
Mailing Address - Country:US
Mailing Address - Phone:203-378-4779
Mailing Address - Fax:302-378-3789
Practice Address - Street 1:114 SANDHILL DR
Practice Address - Street 2:SUITE 101
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-5805
Practice Address - Country:US
Practice Address - Phone:203-378-4779
Practice Address - Fax:302-378-3789
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-29
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELG-000450363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily