Provider Demographics
NPI:1689636649
Name:ELLERN, JEANNE M (PAC)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:M
Last Name:ELLERN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 N HUTCHINSON RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99212-2444
Mailing Address - Country:US
Mailing Address - Phone:509-456-7414
Mailing Address - Fax:509-624-0763
Practice Address - Street 1:1807 N HUTCHINSON RD
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99212-2444
Practice Address - Country:US
Practice Address - Phone:509-456-7414
Practice Address - Fax:509-624-0763
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003760363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAS65857Medicare UPIN
WA8864846Medicare PIN