Provider Demographics
NPI:1043628233
Name:FORSSBERG, JACQUELYN RENE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:RENE
Last Name:FORSSBERG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 COMMODORE ST
Mailing Address - Street 2:
Mailing Address - City:PRATT
Mailing Address - State:KS
Mailing Address - Zip Code:67124-2903
Mailing Address - Country:US
Mailing Address - Phone:620-450-1186
Mailing Address - Fax:
Practice Address - Street 1:1021 EISENHOWER AVE
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530
Practice Address - Country:US
Practice Address - Phone:620-792-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-76350-092363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics