Provider Demographics
NPI:1073185245
Name:ELLERBE, JACK L JR (MSW, LCAS)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:L
Last Name:ELLERBE
Suffix:JR
Gender:M
Credentials:MSW, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 259
Mailing Address - Street 2:
Mailing Address - City:GOLD HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28071-0259
Mailing Address - Country:US
Mailing Address - Phone:704-279-1199
Mailing Address - Fax:704-279-7668
Practice Address - Street 1:665 TIMBER TRL
Practice Address - Street 2:
Practice Address - City:GOLD HILL
Practice Address - State:NC
Practice Address - Zip Code:28071-7500
Practice Address - Country:US
Practice Address - Phone:704-279-1199
Practice Address - Fax:704-279-7668
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)