Provider Demographics
NPI:1033289525
Name:ELLIS, JACK (PT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-1111
Mailing Address - Country:US
Mailing Address - Phone:205-327-5030
Mailing Address - Fax:205-327-5616
Practice Address - Street 1:820 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1111
Practice Address - Country:US
Practice Address - Phone:205-327-5030
Practice Address - Fax:205-327-5616
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH4693225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist