Provider Demographics
NPI:1285823278
Name:ELLISON, JACKLYN ELIZABETH (MSW, CADC, PLCSW)
Entity Type:Individual
Prefix:MRS
First Name:JACKLYN
Middle Name:ELIZABETH
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MSW, CADC, PLCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E LAHARPE ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4520
Mailing Address - Country:US
Mailing Address - Phone:660-665-1962
Mailing Address - Fax:660-665-3989
Practice Address - Street 1:4355 PARIS GRAVEL RD
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6017
Practice Address - Country:US
Practice Address - Phone:573-248-3811
Practice Address - Fax:573-248-3080
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006021234101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional