Provider Demographics
NPI:1831497353
Name:ELLIS, JESSICA ANN (CNM)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 RIVERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5256
Mailing Address - Country:US
Mailing Address - Phone:770-720-7733
Mailing Address - Fax:678-493-9875
Practice Address - Street 1:2525 E BROADWAY ST
Practice Address - Street 2:STE 204
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-8049
Practice Address - Country:US
Practice Address - Phone:406-457-4366
Practice Address - Fax:406-457-4367
Is Sole Proprietor?:No
Enumeration Date:2011-03-08
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA326666OtherGEORGIA LICENSE
MT39957OtherSTATE LICENSE NUMBER