Provider Demographics
NPI:1255395612
Name:ELLIS, JOLENE (MD)
Entity type:Individual
Prefix:
First Name:JOLENE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2048
Mailing Address - Country:US
Mailing Address - Phone:517-780-9260
Mailing Address - Fax:517-780-9263
Practice Address - Street 1:760 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2048
Practice Address - Country:US
Practice Address - Phone:517-780-9260
Practice Address - Fax:517-780-9263
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058029208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4649460Medicaid
MI4649460Medicaid
MIM53750065Medicare ID - Type Unspecified