Provider Demographics
NPI:1558684183
Name:JACKSON, KRISTINA GAYLE (CRNA)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:GAYLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5587
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77726-5587
Mailing Address - Country:US
Mailing Address - Phone:409-838-5214
Mailing Address - Fax:
Practice Address - Street 1:755 N 11TH ST
Practice Address - Street 2:SUITE P3600
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1500
Practice Address - Country:US
Practice Address - Phone:409-838-5214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-10
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000142813163W00000X
TNAPN 15075367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4266382OtherBLUE CROSS OF TN
MS07805512Medicaid
TNP00907129OtherRAILROAD MEDICARE
TN1521274Medicaid
TN1558684183OtherCHAMPUS/HUMANA TRICARE
TN4266382OtherBLUE CROSS OF TN