Provider Demographics
NPI:1568042281
Name:ELLIS-JACKSON, CARMEN CAMILLE (RN)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:CAMILLE
Last Name:ELLIS-JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 N WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-2845
Mailing Address - Country:US
Mailing Address - Phone:856-405-4336
Mailing Address - Fax:856-690-5229
Practice Address - Street 1:524 N WEST BLVD
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-2845
Practice Address - Country:US
Practice Address - Phone:856-405-4336
Practice Address - Fax:856-690-5224
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NO08768100163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontologyGroup - Multi-Specialty