Provider Demographics
NPI:1780853655
Name:JACKSON, CRISTY (PA-C)
Entity Type:Individual
Prefix:
First Name:CRISTY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 N EAGLE CREEK DR
Mailing Address - Street 2:STE 400
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-9038
Mailing Address - Country:US
Mailing Address - Phone:859-226-0031
Mailing Address - Fax:859-226-0041
Practice Address - Street 1:161 N EAGLE CREEK DR
Practice Address - Street 2:STE 400
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-9038
Practice Address - Country:US
Practice Address - Phone:859-226-0031
Practice Address - Fax:859-226-0041
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA810363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1060002OtherNCCPA
KY7100042780Medicaid
KY1060002OtherNCCPA