Provider Demographics
NPI:1639453772
Name:JACKSON, KRYSTEN ASHLEY (PT)
Entity Type:Individual
Prefix:
First Name:KRYSTEN
Middle Name:ASHLEY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRYSTEN
Other - Middle Name:ASHLEY
Other - Last Name:KEENER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:200 NEWPORT CENTER DR
Mailing Address - Street 2:213
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7501
Mailing Address - Country:US
Mailing Address - Phone:949-644-1322
Mailing Address - Fax:949-644-0316
Practice Address - Street 1:6930 WARNER AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-5316
Practice Address - Country:US
Practice Address - Phone:714-847-3800
Practice Address - Fax:714-847-1413
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38636225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFT242ZMedicare PIN