Provider Demographics
NPI:1902044902
Name:ELLIS, JODY (EAMP, LAC, MSA)
Entity Type:Individual
Prefix:MRS
First Name:JODY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:EAMP, LAC, MSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3321
Mailing Address - Street 2:
Mailing Address - City:BELFAIR
Mailing Address - State:WA
Mailing Address - Zip Code:98528-3321
Mailing Address - Country:US
Mailing Address - Phone:360-265-4141
Mailing Address - Fax:
Practice Address - Street 1:23552 NE STATE ROUTE 3 STE 2
Practice Address - Street 2:
Practice Address - City:BELFAIR
Practice Address - State:WA
Practice Address - Zip Code:98528-8335
Practice Address - Country:US
Practice Address - Phone:360-265-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2017-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60028600171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist