Provider Demographics
NPI:1639593148
Name:JACKSON, KRISTAN (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:KRISTAN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 W HURON ST
Mailing Address - Street 2:APT 207
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3432
Mailing Address - Country:US
Mailing Address - Phone:804-814-3104
Mailing Address - Fax:
Practice Address - Street 1:520 W HURON ST
Practice Address - Street 2:APT 207
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3432
Practice Address - Country:US
Practice Address - Phone:804-814-3104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056010441225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist