Provider Demographics
NPI:1891765970
Name:JACKSON, KRISTIE (APN)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 20TH AVE N STE 403
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-5180
Mailing Address - Country:US
Mailing Address - Phone:615-284-7260
Mailing Address - Fax:615-284-7501
Practice Address - Street 1:4230 HARDING PIKE
Practice Address - Street 2:SUITE 330
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37205
Practice Address - Country:US
Practice Address - Phone:615-269-4545
Practice Address - Fax:615-565-6789
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000010926363L00000X
TN2004003624363LA2100X
TN10926363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1519858Medicaid
TN6011957OtherBCBS
TNP01167551OtherRR MEDICARE
TN10350I4975Medicare PIN