Healthcare Provider Details

I. General information

NPI: 1164760500
Provider Name (Legal Business Name): KRISTEN B JACKSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2013
Last Update Date: 01/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 MEDICAL CENTER DR DODD HALL 2145
COLUMBUS OH
43210-1229
US

IV. Provider business mailing address

480 MEDICAL CENTER DR DODD HALL 2145
COLUMBUS OH
43210-1229
US

V. Phone/Fax

Practice location:
  • Phone: 614-293-3830
  • Fax: 614-293-4870
Mailing address:
  • Phone: 614-293-3830
  • Fax: 614-293-4870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: