Provider Demographics
NPI:1255727061
Name:JACKSON, KRISTEN (RN, BSN)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4028 CONNORS WAY
Mailing Address - Street 2:
Mailing Address - City:BLASDELL
Mailing Address - State:NY
Mailing Address - Zip Code:14219-2985
Mailing Address - Country:US
Mailing Address - Phone:631-514-5308
Mailing Address - Fax:
Practice Address - Street 1:4028 CONNORS WAY
Practice Address - Street 2:
Practice Address - City:BLASDELL
Practice Address - State:NY
Practice Address - Zip Code:14219-2985
Practice Address - Country:US
Practice Address - Phone:631-514-5308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY658192163W00000X, 163WH0200X, 163WN0002X, 163WN0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care
No163WN0003XNursing Service ProvidersRegistered NurseNeonatal, Low-Risk