Provider Demographics
NPI:1255470431
Name:ELLIS, JENNIFER R (PA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:R
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PA
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 4543
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60197-4543
Mailing Address - Country:US
Mailing Address - Phone:847-492-3040
Mailing Address - Fax:847-492-3045
Practice Address - Street 1:5230 OLD ORCHARD RD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1034
Practice Address - Country:US
Practice Address - Phone:800-807-8787
Practice Address - Fax:847-492-3045
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001438363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q48881Medicare UPIN
Q48881Medicare UPIN
IL212041Medicare ID - Type UnspecifiedMEDICARE GROUP #