Provider Demographics
NPI:1598855520
Name:JACKSON, KRISTINE M (ARNP)
Entity type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 162
Mailing Address - Street 2:
Mailing Address - City:EAST DUBUQUE
Mailing Address - State:IL
Mailing Address - Zip Code:61025-0162
Mailing Address - Country:US
Mailing Address - Phone:815-747-3932
Mailing Address - Fax:563-557-4447
Practice Address - Street 1:220 W 7TH ST
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-2375
Practice Address - Country:US
Practice Address - Phone:563-583-6431
Practice Address - Fax:563-557-4447
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAIA F 066142363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0140087Medicaid
IA18814OtherWELLMARK
IA0140087Medicaid