Provider Demographics
NPI:1780835876
Name:ELLIS, JEANNA
Entity Type:Individual
Prefix:
First Name:JEANNA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:JEANNA
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARM D
Mailing Address - Street 1:319 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-2119
Mailing Address - Country:US
Mailing Address - Phone:770-266-6061
Mailing Address - Fax:
Practice Address - Street 1:1305 WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549
Practice Address - Country:US
Practice Address - Phone:706-367-8828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH024387183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist