Provider Demographics
NPI:1598420788
Name:JACKSON, CRISTIN DENISE (DMD)
Entity Type:Individual
Prefix:DR
First Name:CRISTIN
Middle Name:DENISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:VIVIAN
Mailing Address - State:LA
Mailing Address - Zip Code:71082-3314
Mailing Address - Country:US
Mailing Address - Phone:318-375-3235
Mailing Address - Fax:
Practice Address - Street 1:815 S PINE ST
Practice Address - Street 2:
Practice Address - City:VIVIAN
Practice Address - State:LA
Practice Address - Zip Code:71082-3314
Practice Address - Country:US
Practice Address - Phone:318-375-3235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7275122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist