MEDICARE: KRISTA L. JACKSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA 586	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000520426	OTHER	KY	BCBS
3	P00290504	OTHER		RAILROAD

General Provider Information

NPI Number	:	1457330227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTA L. JACKSON PA-C

Provider Business Mailing Address
First Line	:	PO BOX 406
Second Line	:
City	:	PRESTONSBURG
State	:	KY
Zip	:	41653-0406
Country	:	US
Telephone Number	:	606-889-6185
Fax Number	:	606-889-6186

Provider Business Practice Location Address
First Line	:	5000 KY ROUTE 321
Second Line	:	SUITE 2162
City	:	PRESTONSBURG
State	:	KY
Zip	:	41653-9113
Country	:	US
Telephone Number	:	606-889-6185
Fax Number	:	606-889-6186

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2006
Last Update Date	:	05/15/2015

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