Provider Demographics
NPI:1780654608
Name:ELLEGOOD, JENNIFER L (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:ELLEGOOD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4841 MONROE ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4385
Mailing Address - Country:US
Mailing Address - Phone:419-471-0493
Mailing Address - Fax:419-472-2772
Practice Address - Street 1:5200 HARROUN RD
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2168
Practice Address - Country:US
Practice Address - Phone:419-824-1952
Practice Address - Fax:419-824-1751
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-002331363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH50-002331OtherPA LICENSE
OHP00354306OtherRR MEDICARE
OHP00354306OtherRR MEDICARE
OHSPPA25782Medicare ID - Type Unspecified9306182
OHSPPA25781Medicare ID - Type Unspecified9306181