Provider Demographics
NPI:1104955806
Name:JACKSON, KRISTEN L (OTR)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2023 BEEBE RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05855-8976
Mailing Address - Country:US
Mailing Address - Phone:802-274-0369
Mailing Address - Fax:
Practice Address - Street 1:2023 BEEBE RD
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855-8976
Practice Address - Country:US
Practice Address - Phone:802-274-0369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT072-0000553225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist