Provider Demographics
NPI:1669927984
Name:ELLISON, JENNIFER (FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ELLISON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:O'CONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3132 OLD JACKSONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7400
Mailing Address - Country:US
Mailing Address - Phone:217-862-0800
Mailing Address - Fax:
Practice Address - Street 1:3132 OLD JACKSONVILLE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7400
Practice Address - Country:US
Practice Address - Phone:217-862-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014641363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner