Healthcare Provider Details

I. General information

NPI: 1255727061
Provider Name (Legal Business Name): KRISTEN JACKSON RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2015
Last Update Date: 04/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4028 CONNORS WAY
BLASDELL NY
14219-2985
US

IV. Provider business mailing address

4028 CONNORS WAY
BLASDELL NY
14219-2985
US

V. Phone/Fax

Practice location:
  • Phone: 631-514-5308
  • Fax:
Mailing address:
  • Phone: 631-514-5308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number658192
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number658192
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number658192
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code163WN0003X
TaxonomyLow-Risk Neonatal Registered Nurse
License Number658192
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: