Provider Demographics
NPI:1043631237
Name:ELLIS, JENNIFER (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOYLETON
Mailing Address - State:IL
Mailing Address - Zip Code:62803-2006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HOYLETON
Practice Address - State:IL
Practice Address - Zip Code:62803-2006
Practice Address - Country:US
Practice Address - Phone:618-493-7382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
IL149.0263881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker