Provider Demographics
NPI:1326029356
Name:NELSON, JACQUELINE J (CRNA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:J
Last Name:NELSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:J
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:8901 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2409
Practice Address - Country:US
Practice Address - Phone:414-328-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD100610367500000X
WI3328367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44369200Medicaid
IA0469619Medicaid
IA39204OtherWELLMARK BCBS
IA0469619Medicaid
IAI15466Medicare PIN