Provider Demographics
NPI:1902204431
Name:ELLIS, JAN (LCSW)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 TIGER ST
Mailing Address - Street 2:
Mailing Address - City:SAINT REGIS
Mailing Address - State:MT
Mailing Address - Zip Code:59866-9757
Mailing Address - Country:US
Mailing Address - Phone:406-649-2311
Mailing Address - Fax:
Practice Address - Street 1:3738 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-6823
Practice Address - Country:US
Practice Address - Phone:406-497-7894
Practice Address - Fax:406-497-7918
Is Sole Proprietor?:No
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT97601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical