Provider Demographics
NPI:1679677272
Name:KISER, JOLENE A
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:A
Last Name:KISER
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 1:2911 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-6217
Mailing Address - Country:US
Mailing Address - Phone:217-653-5048
Mailing Address - Fax:
Practice Address - Street 1:1707 N 12TH ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-1355
Practice Address - Country:US
Practice Address - Phone:217-222-8641
Practice Address - Fax:217-222-1375
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490057121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical