Provider Demographics
NPI:1356529358
Name:ELLIS, JESSICA ERIN (RN)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:ERIN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:ERIN
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:306 PELHAM ST
Mailing Address - Street 2:
Mailing Address - City:CHICKASAW
Mailing Address - State:AL
Mailing Address - Zip Code:36611-2410
Mailing Address - Country:US
Mailing Address - Phone:205-902-4928
Mailing Address - Fax:
Practice Address - Street 1:500 BETHANY WOODS DR
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:GA
Practice Address - Zip Code:30179-3574
Practice Address - Country:US
Practice Address - Phone:205-902-4928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN189320163W00000X
AL1-107940163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse