Provider Demographics
NPI:1316465347
Name:JACKSON, KRISTEN (FNP-C)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2608
Mailing Address - Country:US
Mailing Address - Phone:309-647-0201
Mailing Address - Fax:309-647-8613
Practice Address - Street 1:1024 N MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:ELMWOOD
Practice Address - State:IL
Practice Address - Zip Code:61529-9602
Practice Address - Country:US
Practice Address - Phone:309-742-6334
Practice Address - Fax:309-649-6880
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041412141163W00000X
IL209016808363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse