Provider Demographics
NPI:1841839339
Name:JACKSON, KRISTEN (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTEN
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 1:6001 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-7380
Mailing Address - Country:US
Mailing Address - Phone:724-933-3850
Mailing Address - Fax:
Practice Address - Street 1:6001 STONEWOOD DR
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-7380
Practice Address - Country:US
Practice Address - Phone:724-933-3850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061320363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical