Provider Demographics
NPI:1891476164
Name:TRUSSELL, JACQUSIE LAVERN
Entity Type:Individual
Prefix:
First Name:JACQUSIE
Middle Name:LAVERN
Last Name:TRUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6105 W SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-3146
Mailing Address - Country:US
Mailing Address - Phone:262-336-0065
Mailing Address - Fax:262-336-0065
Practice Address - Street 1:6105 W SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-3146
Practice Address - Country:US
Practice Address - Phone:262-336-0056
Practice Address - Fax:262-336-0065
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI251B00000X163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management