Healthcare Provider Details

I. General information

NPI: 1447600770
Provider Name (Legal Business Name): KRISTINA JACKSON CLC, MSLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5160 DOGWOOD TRL
EIGHT MILE AL
36613-8505
US

IV. Provider business mailing address

5160 DOGWOOD TRL
EIGHT MILE AL
36613-8505
US

V. Phone/Fax

Practice location:
  • Phone: 205-267-3100
  • Fax:
Mailing address:
  • Phone: 205-267-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: