Provider Demographics
NPI:1346385978
Name:ELLIS, JON B (PHD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:B
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 PRINCETON RD
Mailing Address - Street 2:SUITE 21
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-2058
Mailing Address - Country:US
Mailing Address - Phone:423-282-8182
Mailing Address - Fax:423-283-0031
Practice Address - Street 1:206 PRINCETON RD
Practice Address - Street 2:SUITE 21
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-2058
Practice Address - Country:US
Practice Address - Phone:423-282-8182
Practice Address - Fax:423-283-0031
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP1437103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4019151OtherBCBS NUMBER
TN3689850Medicaid
TN3689850Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL NUMBE