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General NPI Number Information
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NPI Number | 1497398697
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Entity Type | Individual
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Provider Name | KRISTIN BURCH JACKSON PT, DPT, CMTPT
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Gender | Female
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Dates
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Enumeration Date | 10/21/2019
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Last Update Date | 12/09/2020
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Provider Practice Location Address
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Address Line | 317 WALLACE AVE STE 203
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City | LOUISVILLE
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State | KY
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Zip | 40207-3060
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Country | US
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Telephone | 502-209-7677
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Fax |
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Provider Business Mailing Address
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Address Line | 4710 KITTY HAWK WAY
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City | LOUISVILLE
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State | KY
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Zip | 40207-1753
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Country | US
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Telephone | 859-619-2349
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | 004956
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License Number State | KY
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