Provider Demographics
NPI:1225391006
Name:JACKSON, KRISTINA ASHLEY (PSYD)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:ASHLEY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2928 W 36TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-1410
Mailing Address - Country:US
Mailing Address - Phone:718-372-3300
Mailing Address - Fax:718-996-8758
Practice Address - Street 1:2928 W 36TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-1410
Practice Address - Country:US
Practice Address - Phone:718-372-3300
Practice Address - Fax:718-996-8758
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NY022353103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00057385Medicaid