Provider Demographics
NPI:1679864128
Name:ELLISON, JEFFREY DONALD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DONALD
Last Name:ELLISON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 W. 22ND ST
Mailing Address - Street 2:PO BOX 5046
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5046
Mailing Address - Country:US
Mailing Address - Phone:605-336-3230
Mailing Address - Fax:605-333-5387
Practice Address - Street 1:113 COMANCHE RD
Practice Address - Street 2:
Practice Address - City:FORT MEADE
Practice Address - State:SD
Practice Address - Zip Code:57741-1002
Practice Address - Country:US
Practice Address - Phone:605-347-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-02
Last Update Date:2024-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD492103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical