Provider Demographics
NPI:1174804678
Name:JACKSON, KRISTEN M (MA, CCC-SLP, L-KS)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP, L-KS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 LOCKETT LN
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:KS
Mailing Address - Zip Code:66535-9618
Mailing Address - Country:US
Mailing Address - Phone:785-494-8676
Mailing Address - Fax:
Practice Address - Street 1:114 LOCKETT LN
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:KS
Practice Address - Zip Code:66535-9618
Practice Address - Country:US
Practice Address - Phone:785-494-8676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2043235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist