Provider Demographics
NPI:1649559873
Name:ELLISON, JEFFREY HUGH (BS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:HUGH
Last Name:ELLISON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1904
Mailing Address - Fax:704-867-2134
Practice Address - Street 1:409 S OAKLAND ST
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-4312
Practice Address - Country:US
Practice Address - Phone:704-874-9005
Practice Address - Fax:704-874-9001
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4890103TC0700X
NC4630103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical