1205847845 NPI number — KRISTINE M STAHELI JACKSON

Table of content: (NPI 1205847845)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205847845 NPI number — KRISTINE M STAHELI JACKSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KRISTINE M STAHELI JACKSON
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205847845
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 116
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBUQUE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52004-0116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HILLCREST FAMILY SERVICES CLINIC
Provider Second Line Business Practice Location Address:
220 W 7TH ST
Provider Business Practice Location Address City Name:
DUBUQUE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-583-6431
Provider Business Practice Location Address Fax Number:
563-557-4447
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GANSEMER
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
563-583-7357

Provider Taxonomy Codes

  • Taxonomy code: 332900000X , with the licence number:  F066142 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0140087 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1621653 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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