Provider Demographics
NPI:1740780337
Name:ELLIS, JILL MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-1235
Mailing Address - Country:US
Mailing Address - Phone:517-862-0800
Mailing Address - Fax:
Practice Address - Street 1:3394 E JOLLY RD STE B
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-8595
Practice Address - Country:US
Practice Address - Phone:517-975-3520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000113225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant