Provider Demographics
NPI:1023008638
Name:ELLIS, JEROME L
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:L
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 JABARRAH AVE
Mailing Address - Street 2:SEYMOUR JOHNSON AFB
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27531-2310
Mailing Address - Country:US
Mailing Address - Phone:919-722-0928
Mailing Address - Fax:919-722-1952
Practice Address - Street 1:1050 JABARRAH AVE
Practice Address - Street 2:SEYMOUR JOHNSON AFB
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27531-2310
Practice Address - Country:US
Practice Address - Phone:919-722-0928
Practice Address - Fax:919-722-1952
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0041191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical