Provider Demographics
NPI:1962850800
Name:ELLIS, JESSICA J (RDH)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:J
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 BEEMAN PL
Mailing Address - Street 2:US ARMY DENTAL ACTIVITY
Mailing Address - City:FT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-7009
Mailing Address - Country:US
Mailing Address - Phone:785-239-4261
Mailing Address - Fax:
Practice Address - Street 1:228 BEEMAN PL
Practice Address - Street 2:US ARMY DENTAL ACTIVITY
Practice Address - City:FT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-7009
Practice Address - Country:US
Practice Address - Phone:785-239-4261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10853124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist