Provider Demographics
NPI:1093102741
Name:JEFFREY K. ELLENS, PH.D. PLC
Entity Type:Organization
Organization Name:JEFFREY K. ELLENS, PH.D. PLC
Other - Org Name:LOTUS COUNSELING OF MONTANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-807-7143
Mailing Address - Street 1:1045 76TH ST
Mailing Address - Street 2:SUITE 3030
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-5834
Mailing Address - Country:US
Mailing Address - Phone:515-777-3388
Mailing Address - Fax:515-777-3387
Practice Address - Street 1:106 E BABCOCK ST STE 1B
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-4820
Practice Address - Country:US
Practice Address - Phone:406-577-2410
Practice Address - Fax:406-573-1070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-21
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001132103TC0700X
103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty