Basic Information
| Provider Information | |||||||||
| NPI: | 1174742985 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLINE | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | LITTON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 S ILLINOIS AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | MASON CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504015489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6414283041 | ||||||||
| FaxNumber: | 6414283059 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 N MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAMPTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506591142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6413942151 | ||||||||
| FaxNumber: | 6413941999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 04-32731 | KS | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 39113 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200566670D | 05 | KS | MEDICAID |