Provider Demographics
NPI:1891159398
Name:BERRYMAN, JACKIE LOUISE (APRN/CNS)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:LOUISE
Last Name:BERRYMAN
Suffix:
Gender:F
Credentials:APRN/CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 SE STONE RD
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:KS
Mailing Address - Zip Code:67042-5500
Mailing Address - Country:US
Mailing Address - Phone:316-320-7766
Mailing Address - Fax:
Practice Address - Street 1:623 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:KS
Practice Address - Zip Code:67152-3207
Practice Address - Country:US
Practice Address - Phone:620-968-7076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13033749011 74471364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care