Provider Demographics
NPI:1225339260
Name:ELLISON, JAKIME LAMAR (P-LCSW)
Entity Type:Individual
Prefix:MR
First Name:JAKIME
Middle Name:LAMAR
Last Name:ELLISON
Suffix:
Gender:M
Credentials:P-LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 CREEK RIDGE RD
Mailing Address - Street 2:LOT# 142
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-4821
Mailing Address - Country:US
Mailing Address - Phone:336-253-0547
Mailing Address - Fax:
Practice Address - Street 1:3405 W WENDOVER AVE
Practice Address - Street 2:SUITE A
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-2377
Practice Address - Country:US
Practice Address - Phone:336-235-2427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NCP0060951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health