Provider Demographics
NPI:1295134732
Name:ELLENBROOK, JADE (MA, LLP)
Entity type:Individual
Prefix:MRS
First Name:JADE
Middle Name:
Last Name:ELLENBROOK
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23810 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1830
Mailing Address - Country:US
Mailing Address - Phone:313-757-1391
Mailing Address - Fax:313-359-4811
Practice Address - Street 1:23810 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1830
Practice Address - Country:US
Practice Address - Phone:313-757-1391
Practice Address - Fax:313-359-4811
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361006204103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical