Jacqueline M Gustafson, CPNP

Primary specialty

Pediatric Nurse PractitionerTaxonomy code 363LP0200X

License

R1423754 Issued in MN

Practice address

2525 Chicago Ave S
Childrens Specialty Clinic Feeding Clinic MPLS
Minneapolis, MN 55404

Phone

(651) 220-6446

Fax

(651) 220-6860

NPI assigned

Feb 22, 2006

Sex

Female

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Certified Pediatric Nurse Practitioner, Nurse Practitioner

State licenses

Practice roles

Locations

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

• Park Nicollet Clinic

  • Family Medicine Physician
  • St Louis Park, MN
  • NPI 1780621904
  Medicare reassignment NPD
• Park Nicollet Clinic

  • Family Medicine Physician
  • St Louis Park, MN
  • NPI 1063897593
  NPD
• Park Nicollet Methodist Hospital

  • General Acute Care Hospital
  • St Louis Park, MN
  • NPI 1194113217
  NPD
• Childrens Health Care

  • Children's Hospital
  • Saint Paul, MN
  • NPI 1629161781
  NPD (past)

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

{
    "created_epoch": "1140566400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1439164800000",
    "number": "1760457527",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2910 CENTRE POINTE DR",
            "address_2": "35-121A CHILDRENS HEALTH CARE",
            "city": "ROSEVILLE",
            "state": "MN",
            "postal_code": "55113",
            "telephone_number": "651-855-2109",
            "fax_number": "651-855-2310"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2525 CHICAGO AVE S",
            "address_2": "CHILDRENS SPECIALTY CLINIC FEEDING CLINIC MPLS",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "55404",
            "telephone_number": "651-220-6446",
            "fax_number": "651-220-6860"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GUSTAFSON",
        "first_name": "JACQUELINE",
        "middle_name": "M",
        "credential": "CPNP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-02-22",
        "last_updated": "2015-08-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0200X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Pediatrics",
            "state": "MN",
            "license": "R1423754",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "928198300",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Alyssa Gustafson, MSN, CNP, NNP-BC
• Amanda Gustafson
• Anna Marie Gustafson, RDN
• Ellen Gustafson
• Grant Joseph Gustafson
• Janelle Marie Gustafson, CTRS
• Jeremy Gustafson, PHARM D
• Kimara Linell Gustafson, M.D., M.P.H
• Linda Rose Gustafson, PT
• Marisa Irene Gustafson, LICSW

• Pediatric Nurse Practitioner in Minneapolis, MN
• Providers in Minneapolis, MN by specialty
• Pediatric Nurse Practitioner in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 10, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.