Healthcare Provider Details

I. General information

NPI: 1780500892
Provider Name (Legal Business Name): KRISTLE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

571 COUNTY ROAD A
GREEN LAKE WI
54941-8630
US

IV. Provider business mailing address

227 N WESTHAVEN DR APT X206
OSHKOSH WI
54904-7689
US

V. Phone/Fax

Practice location:
  • Phone: 920-294-4070
  • Fax: 920-294-4139
Mailing address:
  • Phone: 920-294-4070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12345-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: