Healthcare Provider Details

I. General information

NPI: 1558215632
Provider Name (Legal Business Name): KRISTINA MARIE JUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2026
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 MAPLEWOOD LN
WATERLOO IL
62298-2797
US

IV. Provider business mailing address

1112 MAPLEWOOD LN
WATERLOO IL
62298-2797
US

V. Phone/Fax

Practice location:
  • Phone: 618-604-3974
  • Fax:
Mailing address:
  • Phone: 618-604-3974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0003X
TaxonomyInpatient Obstetric Registered Nurse
License Number2010019358
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: