Basic Information
Provider Information | |||||||||
NPI: | 1740578707 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACKSON | ||||||||
FirstName: | KRISTIN | ||||||||
MiddleName: | ANN MONNAT | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MONNAT | ||||||||
OtherFirstName: | KRISTIN | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1236 E ELIZABETH ST | ||||||||
Address2: | SUITE 1 | ||||||||
City: | FORT COLLINS | ||||||||
State: | CO | ||||||||
PostalCode: | 805244000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702242985 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1236 E ELIZABETH ST | ||||||||
Address2: | SUITE 1 | ||||||||
City: | FORT COLLINS | ||||||||
State: | CO | ||||||||
PostalCode: | 805244000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702242985 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2011 | ||||||||
LastUpdateDate: | 03/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN.0169297 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 11154870 | 05 | CO |   | MEDICAID | 137001400 | 05 | WY |   | MEDICAID | P01316455 | 01 | CO | RR MEDICARE | OTHER |