Provider Demographics
NPI:1467570432
Name:ELLSWORTH, JAMIE (SLP)
Entity Type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 S EAST ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-6704
Mailing Address - Country:US
Mailing Address - Phone:309-827-8004
Mailing Address - Fax:
Practice Address - Street 1:700 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3244
Practice Address - Country:US
Practice Address - Phone:309-827-8004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist