Provider Demographics
NPI:1902230634
Name:JAMISON, ELLISHIONA (COTA)
Entity Type:Individual
Prefix:MS
First Name:ELLISHIONA
Middle Name:
Last Name:JAMISON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7840 PALAWAN WAY
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-2209
Mailing Address - Country:US
Mailing Address - Phone:317-489-1365
Mailing Address - Fax:
Practice Address - Street 1:7465 MADISON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-6564
Practice Address - Country:US
Practice Address - Phone:317-788-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002443A172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker