Provider Demographics
NPI:1710444195
Name:ELISE, JACQUELINE (APRN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ELISE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-3646
Mailing Address - Country:US
Mailing Address - Phone:612-298-3241
Mailing Address - Fax:
Practice Address - Street 1:400 W CAMPUS DR
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-3646
Practice Address - Country:US
Practice Address - Phone:612-298-3241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2025-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT15039363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health