Provider Demographics
NPI:1821680737
Name:ELLIS, JORGONNE MARIE
Entity Type:Individual
Prefix:
First Name:JORGONNE
Middle Name:MARIE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 EAST AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-3913
Mailing Address - Country:US
Mailing Address - Phone:516-309-9914
Mailing Address - Fax:
Practice Address - Street 1:9027 SUTPHIN BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-3647
Practice Address - Country:US
Practice Address - Phone:718-526-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty