Provider Demographics
NPI:1851529986
Name:ELIS, JESSE (DPT)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:ELIS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7007 E GOLD DUST AVE APT 1080
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-1441
Mailing Address - Country:US
Mailing Address - Phone:701-290-8636
Mailing Address - Fax:
Practice Address - Street 1:5111 N SCOTTSDALE RD UNIT 31
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85250-7075
Practice Address - Country:US
Practice Address - Phone:480-990-1379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-26
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8515PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist