Provider Demographics
NPI:1861910499
Name:JACKSON, KRISTEN STAPLES (MCD)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:STAPLES
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 BEAUCLAIR DR
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680
Mailing Address - Country:US
Mailing Address - Phone:803-351-7783
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:864-331-1344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-04
Last Update Date:2017-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6369235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist