Provider Demographics
NPI:1962011320
Name:HACKETT, KRISTINE MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:MARIE
Last Name:HACKETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 BABBITT CT
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-2955
Mailing Address - Country:US
Mailing Address - Phone:602-510-3983
Mailing Address - Fax:
Practice Address - Street 1:19301 SE 34TH ST STE 104
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-8881
Practice Address - Country:US
Practice Address - Phone:360-254-2318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61086172152W00000X
ORATI4526152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist