Provider Demographics
NPI:1063885333
Name:JACKSON, KRISTYNE
Entity type:Individual
Prefix:
First Name:KRISTYNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISSY
Other - Middle Name:
Other - Last Name:WHITELEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10395 E 500 S
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46989-9447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 W 8TH ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-2659
Practice Address - Country:US
Practice Address - Phone:765-810-0830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-08
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
IN34009745A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program