Provider Demographics
NPI:1134597677
Name:RUSCO, JENNIFER (FNP-BC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RUSCO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 S MAIN ST
Mailing Address - Street 2:STE 1300
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-5513
Mailing Address - Country:US
Mailing Address - Phone:901-422-7617
Mailing Address - Fax:
Practice Address - Street 1:50 S B B KING BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2626
Practice Address - Country:US
Practice Address - Phone:901-422-7644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-14
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277000881363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209012912Medicaid