Healthcare Provider Details

I. General information

NPI: 1538096094
Provider Name (Legal Business Name): KRISTIN JACKSON
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2507 N 187TH AVE
ELKHORN NE
68022-4539
US

IV. Provider business mailing address

4805 N 72ND ST
OMAHA NE
68134-2304
US

V. Phone/Fax

Practice location:
  • Phone: 405-962-5688
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: