1659329621 NPI number — DR. JACALYN ANNE BOSSEN KAWIECKI MD, MHA

Table of content: DR. JACALYN ANNE BOSSEN KAWIECKI MD, MHA (NPI 1659329621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659329621 NPI number — DR. JACALYN ANNE BOSSEN KAWIECKI MD, MHA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KAWIECKI
Provider First Name:
JACALYN
Provider Middle Name:
ANNE BOSSEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, MHA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAHL
Provider Other First Name:
JACALYN
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD, MHA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659329621
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6235 WENTWORTH AVE
Provider Second Line Business Mailing Address:
J.A.B. KAWIECKI, INC.; D.B.A. EXCEL REHABILITATION
Provider Business Mailing Address City Name:
RICHFIELD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55423-1540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-481-1233
Provider Business Mailing Address Fax Number:
612-886-3231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1412 W 4TH ST
Provider Second Line Business Practice Location Address:
RED WING HEALTHCARE COMMUNITY
Provider Business Practice Location Address City Name:
RED WING
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55066-2107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-388-2843
Provider Business Practice Location Address Fax Number:
651-388-9502
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  42926 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 206922900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP37218 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 611855422B159 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 81Q7G72KA . This is a "BCBS MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 34247000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 963371033094 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".




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