Provider Demographics
NPI:1114763430
Name:BRUSS, JACKIE ANNE
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:ANNE
Last Name:BRUSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64751 141ST AVE
Mailing Address - Street 2:
Mailing Address - City:WABASHA
Mailing Address - State:MN
Mailing Address - Zip Code:55981-7592
Mailing Address - Country:US
Mailing Address - Phone:507-450-7437
Mailing Address - Fax:
Practice Address - Street 1:125 2ND AVE NW
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:MN
Practice Address - Zip Code:55964-1222
Practice Address - Country:US
Practice Address - Phone:507-951-3830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-05
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN623212164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse