Provider Demographics
NPI:1689710097
Name:ELLIS, JONATHAN W (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:W
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:MA
Mailing Address - Zip Code:02067-2151
Mailing Address - Country:US
Mailing Address - Phone:617-264-5301
Mailing Address - Fax:
Practice Address - Street 1:161 S HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-4885
Practice Address - Country:US
Practice Address - Phone:617-264-5301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2137001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical