Provider Demographics
NPI:1780335273
Name:JEURISSEN, KATHRYN (DNP)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:
Last Name:JEURISSEN
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25360 COUNTY ROUTE 16
Mailing Address - Street 2:
Mailing Address - City:EVANS MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:13637-3104
Mailing Address - Country:US
Mailing Address - Phone:402-540-2097
Mailing Address - Fax:
Practice Address - Street 1:3114 SLEEPY HOLLOW LN
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-7146
Practice Address - Country:US
Practice Address - Phone:402-540-2097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-16
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF349035363LF0000X
TX1141791363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily