Provider Demographics
NPI:1093063950
Name:ELLIS, JESSE LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:LEE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MARLOW
Mailing Address - State:OK
Mailing Address - Zip Code:73055-8691
Mailing Address - Country:US
Mailing Address - Phone:580-721-7007
Mailing Address - Fax:580-721-7008
Practice Address - Street 1:1802 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MARLOW
Practice Address - State:OK
Practice Address - Zip Code:73055-8691
Practice Address - Country:US
Practice Address - Phone:580-721-7007
Practice Address - Fax:580-721-7008
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4076111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor