Provider Demographics
NPI:1740578707
Name:JACKSON, KRISTIN ANN MONNAT (CRNA)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:ANN MONNAT
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:KRISTIN
Other - Middle Name:ANN
Other - Last Name:MONNAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1236 E ELIZABETH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4000
Mailing Address - Country:US
Mailing Address - Phone:970-224-2985
Mailing Address - Fax:
Practice Address - Street 1:1236 E ELIZABETH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4000
Practice Address - Country:US
Practice Address - Phone:970-224-2985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.0169297367500000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11154870Medicaid
WY137001400Medicaid
COP01316455OtherRR MEDICARE
CO263730YTMFMedicare PIN