Provider Demographics
NPI:1336554898
Name:KISZKA, JESSICA (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KISZKA
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9104 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2907
Mailing Address - Country:US
Mailing Address - Phone:219-306-6602
Mailing Address - Fax:
Practice Address - Street 1:9104 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2907
Practice Address - Country:US
Practice Address - Phone:219-836-4473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011602363L00000X
IN71005664A363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner