Provider Demographics
NPI:1467758706
Name:ELLIS, JACQUESHIA LYNETTE (AA)
Entity Type:Individual
Prefix:MS
First Name:JACQUESHIA
Middle Name:LYNETTE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:AA
Other - Prefix:MS
Other - First Name:TWEETY
Other - Middle Name:TWEETY
Other - Last Name:TWEETY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AA
Mailing Address - Street 1:900 W 1ST ST STE 200
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-5587
Mailing Address - Country:US
Mailing Address - Phone:775-677-2216
Mailing Address - Fax:
Practice Address - Street 1:900 W 1ST ST STE 200
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-5587
Practice Address - Country:US
Practice Address - Phone:775-677-2216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV172V00000X172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker