Provider Demographics
NPI:1730829508
Name:KIETZKE, JILL KRISTEN (MSN, BC-ADM)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:KRISTEN
Last Name:KIETZKE
Suffix:
Gender:F
Credentials:MSN, BC-ADM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOREB
Mailing Address - State:WI
Mailing Address - Zip Code:53572-3311
Mailing Address - Country:US
Mailing Address - Phone:608-512-8115
Mailing Address - Fax:
Practice Address - Street 1:640 S 1ST ST
Practice Address - Street 2:
Practice Address - City:MOUNT HOREB
Practice Address - State:WI
Practice Address - Zip Code:53572-3311
Practice Address - Country:US
Practice Address - Phone:608-512-8115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI119707-30163WD0400X
174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator