Provider Demographics
NPI:1851635973
Name:ELLINGSON, JILL (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:ELLINGSON
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 BROADWAY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ST PAUL PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55071-1554
Mailing Address - Country:US
Mailing Address - Phone:612-242-1224
Mailing Address - Fax:651-340-2587
Practice Address - Street 1:445 BROADWAY AVE STE A
Practice Address - Street 2:
Practice Address - City:ST PAUL PARK
Practice Address - State:MN
Practice Address - Zip Code:55071
Practice Address - Country:US
Practice Address - Phone:612-242-1224
Practice Address - Fax:651-340-2587
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
MN2671106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist