Provider Demographics
NPI:1376013326
Name:ELLIS, JIMMY LEE
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:LEE
Last Name:ELLIS
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 1:3420 E SHEA BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3345
Mailing Address - Country:US
Mailing Address - Phone:480-487-8480
Mailing Address - Fax:
Practice Address - Street 1:105 N LINKS DR APT 1061
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-3046
Practice Address - Country:US
Practice Address - Phone:480-487-8480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2019-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker