Provider Demographics
NPI:1043551401
Name:JACKOWIAK, KRISTINA M (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:M
Last Name:JACKOWIAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:M
Other - Last Name:APPELHANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2824 ELKHART RD
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-1014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2824 ELKHART RD
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-1014
Practice Address - Country:US
Practice Address - Phone:574-535-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-11
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN184520063Medicare PIN