Provider Demographics
NPI:1720037724
Name:JACKSON, KRISTIN (DPM)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 1ST ST SE
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-3440
Mailing Address - Country:US
Mailing Address - Phone:320-632-3671
Mailing Address - Fax:320-632-3728
Practice Address - Street 1:1108 1ST ST SE
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-3440
Practice Address - Country:US
Practice Address - Phone:320-632-3671
Practice Address - Fax:320-632-3728
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN612213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN967750000MNMedicaid
MN480000326Medicare PIN
MN480000629Medicare PIN
MNU72883Medicare UPIN