Provider Demographics
NPI:1659329621
Name:KAWIECKI, JACALYN ANNE BOSSEN (MD, MHA)
Entity type:Individual
Prefix:DR
First Name:JACALYN
Middle Name:ANNE BOSSEN
Last Name:KAWIECKI
Suffix:
Gender:F
Credentials:MD, MHA
Other - Prefix:DR
Other - First Name:JACALYN
Other - Middle Name:ANNE
Other - Last Name:DAHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, MHA
Mailing Address - Street 1:6235 WENTWORTH AVE
Mailing Address - Street 2:J.A.B. KAWIECKI, INC.; D.B.A. EXCEL REHABILITATION
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1540
Mailing Address - Country:US
Mailing Address - Phone:612-481-1233
Mailing Address - Fax:612-886-3231
Practice Address - Street 1:1412 W 4TH ST
Practice Address - Street 2:RED WING HEALTHCARE COMMUNITY
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-2107
Practice Address - Country:US
Practice Address - Phone:651-388-2843
Practice Address - Fax:651-388-9502
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42926208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN206922900Medicaid
HP37218OtherHEALTH PARTNERS
611855422B159OtherTRICARE
MN81Q7G72KAOtherBCBS MINNESOTA
WI34247000Medicaid
963371033094OtherPREFERRED ONE
MN250000696Medicare ID - Type Unspecified
H75360Medicare UPIN