Provider Demographics
NPI:1649748666
Name:KRISTIN M JACKSON LLC
Entity Type:Organization
Organization Name:KRISTIN M JACKSON LLC
Other - Org Name:ADVANCED UROGYNECOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-902-7400
Mailing Address - Street 1:260 LOOKOUT PL STE 201
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4485
Mailing Address - Country:US
Mailing Address - Phone:407-898-9804
Mailing Address - Fax:407-898-9805
Practice Address - Street 1:260 LOOKOUT PL STE 201
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4485
Practice Address - Country:US
Practice Address - Phone:407-898-9804
Practice Address - Fax:407-898-9805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-07
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty