Provider Demographics
NPI:1851506380
Name:ELLENSTEIN, JEFFREY (MA, EDM, LPC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:ELLENSTEIN
Suffix:
Gender:M
Credentials:MA, EDM, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-1143
Mailing Address - Country:US
Mailing Address - Phone:269-781-4271
Mailing Address - Fax:
Practice Address - Street 1:200 N MADISON ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-1143
Practice Address - Country:US
Practice Address - Phone:269-789-3912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013144101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401013144OtherLICENSE
MI6401013144OtherLICENSE