Provider Demographics
NPI:1912098252
Name:JACKSON, KRISTEN A (PT,DPT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:A
Other - Last Name:BELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT,DPT
Mailing Address - Street 1:6255 S ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2609
Mailing Address - Country:US
Mailing Address - Phone:773-284-6735
Mailing Address - Fax:773-284-6820
Practice Address - Street 1:6255 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2609
Practice Address - Country:US
Practice Address - Phone:773-284-6735
Practice Address - Fax:773-284-6820
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2209618062251X0800X
IL070-017006225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220961806Medicare ID - Type Unspecified