Provider Demographics
NPI:1770018780
Name:ROGNSTAD, JACQUELYN JOYCE (BSN, RN)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:JOYCE
Last Name:ROGNSTAD
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38675 N HILLTOP AVE
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-9630
Mailing Address - Country:US
Mailing Address - Phone:847-395-4557
Mailing Address - Fax:
Practice Address - Street 1:81 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:FOX LAKE
Practice Address - State:IL
Practice Address - Zip Code:60020-1557
Practice Address - Country:US
Practice Address - Phone:224-908-3005
Practice Address - Fax:815-814-8989
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 261QM2800X, 261QR0405X
IL041.395865163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No251S00000XAgenciesCommunity/Behavioral Health
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1770018780Medicaid