Provider Demographics
NPI:1295303113
Name:ELLISON, JEANNIE (CPHT)
Entity type:Individual
Prefix:
First Name:JEANNIE
Middle Name:
Last Name:ELLISON
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-3750
Mailing Address - Country:US
Mailing Address - Phone:269-488-5460
Mailing Address - Fax:
Practice Address - Street 1:445 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-3750
Practice Address - Country:US
Practice Address - Phone:269-488-3957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303020611374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician