Provider Demographics
NPI:1922476241
Name:WHOLE HEALTH FAMILY PRACTICE, PC
Entity Type:Organization
Organization Name:WHOLE HEALTH FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:S
Authorized Official - Last Name:JESENICK
Authorized Official - Suffix:
Authorized Official - Credentials:APN, FNP-C
Authorized Official - Phone:618-622-1200
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:618-622-1200
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:618-622-1200
Practice Address - Fax:314-270-5283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-02
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006003363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q71686Medicare UPIN