Provider Demographics
NPI:1568746642
Name:ELLIS, JENNIFER LEANNE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEANNE
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 1:1713 NW 148TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-1396
Mailing Address - Country:US
Mailing Address - Phone:405-657-6885
Mailing Address - Fax:405-216-5272
Practice Address - Street 1:1717 W 33RD ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3863
Practice Address - Country:US
Practice Address - Phone:405-216-5608
Practice Address - Fax:405-216-5272
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200123000AMedicaid