Provider Demographics
NPI:1477846186
Name:ELLIS, CHRISTINE L
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:L
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12530 ROCK ROSE LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-4217
Mailing Address - Country:US
Mailing Address - Phone:530-776-0552
Mailing Address - Fax:
Practice Address - Street 1:12530 ROCK ROSE LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-4217
Practice Address - Country:US
Practice Address - Phone:530-776-0552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-27
Last Update Date:2023-10-12
Deactivation Date:2019-06-11
Deactivation Code:
Reactivation Date:2019-09-26
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical