Provider Demographics
NPI:1851683775
Name:ELLIS, JENNIFER (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:FL
Mailing Address - Zip Code:32344-1529
Mailing Address - Country:US
Mailing Address - Phone:850-694-2204
Mailing Address - Fax:850-997-4483
Practice Address - Street 1:180 S CHERRY ST
Practice Address - Street 2:SUITE F
Practice Address - City:MONTICELLO
Practice Address - State:FL
Practice Address - Zip Code:32344-1929
Practice Address - Country:US
Practice Address - Phone:850-694-2204
Practice Address - Fax:850-997-4483
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA30673225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC9973OtherBCBS OF FL