Provider Demographics
NPI:1437766201
Name:ELLISON, JACQUELINE ANN (DNP, ARNP, FNP-C)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ANN
Last Name:ELLISON
Suffix:
Gender:F
Credentials:DNP, ARNP, FNP-C
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:ANN
Other - Last Name:BRUNGARDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2015 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-3000
Mailing Address - Country:US
Mailing Address - Phone:712-732-6650
Mailing Address - Fax:712-732-6632
Practice Address - Street 1:2015 W 5TH ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-3000
Practice Address - Country:US
Practice Address - Phone:712-732-6650
Practice Address - Fax:712-732-6632
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA160841363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily