Provider Demographics
NPI:1770193526
Name:JACKSON, CHRIS (CRT)
Entity type:Individual
Prefix:
First Name:CHRIS
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19615 HARTFORD AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4973
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3067 E COPPER POINT DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1740
Practice Address - Country:US
Practice Address - Phone:208-287-1733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLRT-1569227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified