Healthcare Provider Details

I. General information

NPI: 1437589827
Provider Name (Legal Business Name): KRISTOPHER JACKSON MSN, CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2013
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 WILLOW ST
NEW BEDFORD MA
02740
US

IV. Provider business mailing address

55 FOGG RD
WEYMOUTH MA
02190-2455
US

V. Phone/Fax

Practice location:
  • Phone: 603-781-0155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberSP013313
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN10011850
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: