Healthcare Provider Details

I. General information

NPI: 1710444195
Provider Name (Legal Business Name): JACQUELINE ELISE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W CAMPUS DR
ORANGE CT
06477-3646
US

IV. Provider business mailing address

400 W CAMPUS DR
ORANGE CT
06477-3646
US

V. Phone/Fax

Practice location:
  • Phone: 612-298-3241
  • Fax:
Mailing address:
  • Phone: 612-298-3241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number15039
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: