Healthcare Provider Details

I. General information

NPI: 1023907219
Provider Name (Legal Business Name): KRISTA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SIVLEY RD SW
HUNTSVILLE AL
35801-4421
US

IV. Provider business mailing address

303 KNOTTY WALLS RD SE
OWENS CROSS ROADS AL
35763-9038
US

V. Phone/Fax

Practice location:
  • Phone: 256-265-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF06250801
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: