Provider Demographics
NPI:1346425204
Name:ELLARD, JEREMIAH SERON
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:SERON
Last Name:ELLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4325 N CHESTNUT AVE APT 108
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-2952
Mailing Address - Country:US
Mailing Address - Phone:559-375-2696
Mailing Address - Fax:
Practice Address - Street 1:114 E SHAW AVE STE 210
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-7621
Practice Address - Country:US
Practice Address - Phone:559-221-8100
Practice Address - Fax:559-221-8101
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101076OtherMEDI-CAL