NPIMap

Individual provider Active NPI

Jacqueline Ann Ellison, DNP, ARNP, FNP-C

  • Family Nurse Practitioner
  • Storm Lake, IA
National Provider Identifier
1437766201
Registry record updated Jul 5, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
License
A160841 Issued in IA
Practice address
2015 W 5TH St
Storm Lake, IA 50588-3000
Phone
(712) 732-6650
Fax
(712) 732-6632
NPI assigned
Sep 25, 2020
Last updated
Jul 5, 2023By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jul 5, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X A160841 IA Primary

Addresses

Primary practice location

2015 W 5TH St
Storm Lake, IA 50588-3000

Mailing address

2015 W 5TH St
Storm Lake, IA 50588-3000
Phone (712) 732-6650

Other names 1

  • Jacqueline Ann Brungardt Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20201023002644 IA Practitioner - Nurse Practitioner 1153741533 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
Other, 2020
Medicare assignment
May accept Medicare assignment
Group practices
Trinity Regional Medical CenterGroup PAC ID 7315858529, 170 clinicians
Sports Rehab and Professional Therapy Associates IncGroup PAC ID 1658289608, 124 clinicians

Practice addresses (Care Compare)

1525 W 5TH St
Buena Vista Regional Medical Center
Storm Lake, IA 50588-3027
Phone (712) 732-4030

315 W 5TH St
Storm Lake, IA 50588-1743
Phone (712) 732-7724

520 Otsego St
Storm Lake, IA 50588-1760
Phone (712) 299-4750

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

Practice roles

OrganizationSpecialtyStatusNew patients
Trinity Regional Medical Center CurrentSince Mar 22, 2023 Accepting new patients
St Luke's Methodist Hospital Current Accepting new patients

Locations

802 Kenyon Rd
Fort Dodge, IA 50501
Phone (515) 574-6565

2015 W 5th St
Storm Lake, IA 50588
Phone (717) 732-6650

Interoperability endpoints

  • Direct secure messaging: jellison941473@direct.unitypoint.org
  • Direct secure messaging: jellisonarnp@hornmh.securechart.com

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1600992000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1688515200000",
    "number": "1437766201",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2015 W 5TH ST",
            "city": "STORM LAKE",
            "state": "IA",
            "postal_code": "505883000",
            "telephone_number": "712-732-6650",
            "fax_number": "712-732-6632"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2015 W 5TH ST",
            "city": "STORM LAKE",
            "state": "IA",
            "postal_code": "505883000",
            "telephone_number": "712-732-6650",
            "fax_number": "712-732-6632"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ELLISON",
        "first_name": "JACQUELINE",
        "middle_name": "ANN",
        "name_prefix": "Dr.",
        "credential": "DNP, ARNP, FNP-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2020-09-25",
        "last_updated": "2023-07-05",
        "certification_date": "2023-07-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "IA",
            "license": "A160841",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "JACQUELINE",
            "last_name": "BRUNGARDT",
            "middle_name": "ANN",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in Storm Lake, IA

Sources for this page

Verify at the official NPI Registry.