Provider Demographics
NPI:1245270222
Name:ELLIS, JESSICA LAINE (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAINE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1648
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-1648
Mailing Address - Country:US
Mailing Address - Phone:541-242-4812
Mailing Address - Fax:541-284-2038
Practice Address - Street 1:1435 G ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4113
Practice Address - Country:US
Practice Address - Phone:541-242-4812
Practice Address - Fax:541-242-4813
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD172850207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500694329Medicaid
OR500694329Medicaid
H82372Medicare UPIN
117132OtherHEALTH ALLIANCE
IAI17389Medicare ID - Type Unspecified
IA1286518Medicaid
IAIA01C4OtherJOHN DEERE FAMILY
IA21962OtherWELLMARK