Provider Demographics
NPI:1699441626
Name:ELLSTROM, JENNIFER JEANINE (FNP-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JEANINE
Last Name:ELLSTROM
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:JEANINE
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1756 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-4701
Mailing Address - Country:US
Mailing Address - Phone:801-893-1905
Mailing Address - Fax:
Practice Address - Street 1:3401 N CENTER ST STE 175
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-7502
Practice Address - Country:US
Practice Address - Phone:801-893-1872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12124921-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily