Provider Demographics
NPI:1821061474
Name:JACKSON, KRISTINA M (AUD)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-4500
Mailing Address - Country:US
Mailing Address - Phone:716-833-4488
Mailing Address - Fax:
Practice Address - Street 1:4600 MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-4500
Practice Address - Country:US
Practice Address - Phone:716-833-4488
Practice Address - Fax:716-839-1218
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001607-0231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000580000005OtherBC/BS-HEARING AID-OP
NY000576103001OtherBC/BS-AUDIOLOGIST-H
NY000576103003OtherBC/BS-AUDIOLOGIST-OP
NY00011176701OtherUNIVERA
NY000580000003OtherBC/BS-HEARING AID-H
NY9200301OtherIHA
NYDD0705Medicare ID - Type UnspecifiedMEDICARE