Provider Demographics
NPI:1417129859
Name:ELLIS, JACQUELINE C (LPC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:C
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N JACKSON ST
Mailing Address - Street 2:P.O. DRAWER 1348
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-3015
Mailing Address - Country:US
Mailing Address - Phone:229-931-2470
Mailing Address - Fax:229-931-2474
Practice Address - Street 1:415 N JACKSON ST
Practice Address - Street 2:P.O. DRAWER 1348
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3015
Practice Address - Country:US
Practice Address - Phone:229-931-2470
Practice Address - Fax:229-931-2474
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004305101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional