Provider Demographics
NPI:1356651954
Name:ELLISON, JENNIFER NATASHA ROSE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:NATASHA ROSE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NATASHA
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP, APRN
Mailing Address - Street 1:377 W CAMPBELL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3695
Mailing Address - Country:US
Mailing Address - Phone:585-397-2605
Mailing Address - Fax:
Practice Address - Street 1:377 W CAMPBELL RD STE 100
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3695
Practice Address - Country:US
Practice Address - Phone:469-232-2945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF336423-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily