1275919193 NPI number — JACQUELINE RUSHTON RN, DNP, CRNA

Table of content: (NPI 1720493976)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275919193 NPI number — JACQUELINE RUSHTON RN, DNP, CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSHTON
Provider First Name:
JACQUELINE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, DNP, CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REYNOLDS
Provider Other First Name:
JACQUELINE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN, DNP, CRNA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1275919193
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 W RIVER WOODS PKWY FL 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53212-1060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-660-8141
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 N LAKE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53211-4508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-660-8141
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/03/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  11980-33 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X , with the licence number: 201604923CRNA-PP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100205237 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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