Provider Demographics
NPI:1053407817
Name:JACKSON, KRISTIE LYNN (NP)
Entity type:Individual
Prefix:MRS
First Name:KRISTIE
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 MUDPIKE ROAD
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073
Mailing Address - Country:US
Mailing Address - Phone:540-382-9139
Mailing Address - Fax:
Practice Address - Street 1:3700 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060
Practice Address - Country:US
Practice Address - Phone:540-953-5385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167104363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily