Provider Demographics
NPI:1114921772
Name:JERGENSON, KELLY J (ARNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:JERGENSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-2241
Mailing Address - Country:US
Mailing Address - Phone:563-242-7522
Mailing Address - Fax:563-242-7534
Practice Address - Street 1:221 MAIN AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-2241
Practice Address - Country:US
Practice Address - Phone:563-242-7522
Practice Address - Fax:563-242-7534
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-077904363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI1330Medicare ID - Type Unspecified
IAI1330Medicare PIN
P25283Medicare UPIN