Provider Demographics
NPI:1093252777
Name:ETHRIDGE-BROWN, JILLIAN NICOLE (MSN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:NICOLE
Last Name:ETHRIDGE-BROWN
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:MS
Other - First Name:JILLIAN
Other - Middle Name:NICOLE
Other - Last Name:ETHRIDGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSN, FNP-BC
Mailing Address - Street 1:660A S TRUMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-2235
Mailing Address - Country:US
Mailing Address - Phone:636-931-3800
Mailing Address - Fax:636-931-3911
Practice Address - Street 1:1296 JEFFCO BLVD
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-2138
Practice Address - Country:US
Practice Address - Phone:636-321-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041425190163W00000X
MO2008021433163W00000X, 163WF0300X
MO2016034571363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No163WF0300XNursing Service ProvidersRegistered NurseFlight