Provider Demographics
NPI:1396831616
Name:JESENICK, CRYSTAL S (ANP-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:S
Last Name:JESENICK
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:L
Other - Last Name:SPIRKOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:825 SAYBROOK FALLS DR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-2168
Mailing Address - Country:US
Mailing Address - Phone:618-972-5641
Mailing Address - Fax:314-270-5283
Practice Address - Street 1:922 TALON DR
Practice Address - Street 2:SUITE B
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1848
Practice Address - Country:US
Practice Address - Phone:618-972-5641
Practice Address - Fax:314-270-5283
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006003363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427014204Medicaid
MO427014204Medicaid
ILK39746Medicare PIN
MO990001366Medicare PIN