Provider Demographics
NPI:1205847845
Name:KRISTINE M STAHELI JACKSON
Entity Type:Organization
Organization Name:KRISTINE M STAHELI JACKSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GANSEMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-583-7357
Mailing Address - Street 1:PO BOX 116
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52004-0116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HILLCREST FAMILY SERVICES CLINIC
Practice Address - Street 2:220 W 7TH ST
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001
Practice Address - Country:US
Practice Address - Phone:563-583-6431
Practice Address - Fax:563-557-4447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAF066142332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0140087Medicaid
1621653OtherOTHER ID NUMBER-COMMERCIAL NUMBER
I5400Medicare ID - Type Unspecified