Provider Demographics
NPI:1861455495
Name:ELLIS, JASON (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3965 NORMAL ST
Mailing Address - Street 2:SUIT #4
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3422
Mailing Address - Country:US
Mailing Address - Phone:619-807-0329
Mailing Address - Fax:619-269-5982
Practice Address - Street 1:3965 NORMAL ST
Practice Address - Street 2:SUIT #4
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3422
Practice Address - Country:US
Practice Address - Phone:619-807-0329
Practice Address - Fax:619-269-5982
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29926111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor