Provider Demographics
NPI:1790466704
Name:JACKIEWICZ, KRISTINE
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:JACKIEWICZ
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 1:67 BRINDLETOWN RD
Mailing Address - Street 2:
Mailing Address - City:NEW EGYPT
Mailing Address - State:NJ
Mailing Address - Zip Code:08533-1813
Mailing Address - Country:US
Mailing Address - Phone:215-666-1689
Mailing Address - Fax:
Practice Address - Street 1:67 BRINDLETOWN RD
Practice Address - Street 2:
Practice Address - City:NEW EGYPT
Practice Address - State:NJ
Practice Address - Zip Code:08533-1813
Practice Address - Country:US
Practice Address - Phone:215-666-1689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage