Provider Demographics
NPI:1114466513
Name:STAJCAR, JACQUELYN
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:STAJCAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52544-1737
Mailing Address - Country:US
Mailing Address - Phone:641-895-7620
Mailing Address - Fax:
Practice Address - Street 1:19942 SAINT JOSEPH DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IA
Practice Address - Zip Code:52544-8849
Practice Address - Country:US
Practice Address - Phone:641-856-8684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-17
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA125696363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA125696OtherLICENSE