Provider Demographics
NPI:1386813707
Name:JESBERG, CAROLE A (RN)
Entity Type:Individual
Prefix:MRS
First Name:CAROLE
Middle Name:A
Last Name:JESBERG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:CAROLE
Other - Middle Name:A
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2407
Mailing Address - Country:US
Mailing Address - Phone:218-728-4491
Mailing Address - Fax:218-728-4404
Practice Address - Street 1:1500 N 34TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-4477
Practice Address - Country:US
Practice Address - Phone:715-392-8216
Practice Address - Fax:715-392-6055
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI145190-030163WP0808X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1194994525Medicaid