Provider Demographics
NPI:1629738802
Name:ELLIS, JESSICA R (MS, CF-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:294 KNIGHT RD
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-5240
Mailing Address - Country:US
Mailing Address - Phone:607-240-8776
Mailing Address - Fax:
Practice Address - Street 1:236 BURTS RD
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:NY
Practice Address - Zip Code:13795-1731
Practice Address - Country:US
Practice Address - Phone:877-426-3307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist