Provider Demographics
NPI:1629024799
Name:REGAN, KRISTIN ANN (AUD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:ANN
Last Name:REGAN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:ANN
Other - Last Name:LU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:1410 W GANSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-4063
Mailing Address - Country:US
Mailing Address - Phone:517-962-5063
Mailing Address - Fax:517-962-5209
Practice Address - Street 1:2136 ROBINSON RD STE 3
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203
Practice Address - Country:US
Practice Address - Phone:517-962-5063
Practice Address - Fax:517-962-5209
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000314231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00344284OtherRR MEDICARE
MI4678677Medicaid
MI4678677Medicaid
MIM25090007Medicare PIN