Provider Demographics
NPI:1093252777
Name:ETHRIDGE-BROWN, JILLIAN NICOLE (MSN, FNP-BC)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:NICOLE
Last Name:ETHRIDGE-BROWN
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:MS
Other - First Name:JILLIAN
Other - Middle Name:NICOLE
Other - Last Name:ETHRIDGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSN, FNP-BC
Mailing Address - Street 1:PO BOX 959354
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-2235
Mailing Address - Country:US
Mailing Address - Phone:314-742-6000
Mailing Address - Fax:314-742-6002
Practice Address - Street 1:4438 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-3316
Practice Address - Country:US
Practice Address - Phone:314-742-6000
Practice Address - Fax:314-742-6002
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041425190163W00000X
MO2008021433163W00000X, 163WF0300X
MO2016034571363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No163WF0300XNursing Service ProvidersRegistered NurseFlight
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner