Provider Demographics
NPI:1972839462
Name:ELLSTROM, JENNIFER A (CNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:ELLSTROM
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7117 BROCKTON AVE
Mailing Address - Street 2:RIVERSIDE MEDICAL CLINIC
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2658
Mailing Address - Country:US
Mailing Address - Phone:951-784-3269
Mailing Address - Fax:951-784-3269
Practice Address - Street 1:7117 BROCKTON AVE
Practice Address - Street 2:RIVERSIDE MEDICAL CLINIC
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2658
Practice Address - Country:US
Practice Address - Phone:951-784-3269
Practice Address - Fax:951-784-3269
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-134002-8363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily