Provider Demographics
NPI:1609180819
Name:ELLIS, JENNIFER JEANNE (MA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JEANNE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7745 JONAGOLD DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-7602
Mailing Address - Country:US
Mailing Address - Phone:800-435-2197
Mailing Address - Fax:
Practice Address - Street 1:7745 JONAGOLD DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-7602
Practice Address - Country:US
Practice Address - Phone:616-970-4636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013557101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health