Provider Demographics
NPI:1700914140
Name:ELLIS, JASON LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:LEE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7250 FRANCE AVE S
Mailing Address - Street 2:300A
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4313
Mailing Address - Country:US
Mailing Address - Phone:952-835-4772
Mailing Address - Fax:763-207-8381
Practice Address - Street 1:7250 FRANCE AVE S.
Practice Address - Street 2:300 A
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4346
Practice Address - Country:US
Practice Address - Phone:952-835-4772
Practice Address - Fax:763-207-8381
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4989111N00000X
MI2301009298111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3I335ELOtherBCBS
MNCC1343AOtherCHIROCARE
MN716650OtherACN
MN716650OtherACN
MN060468000Medicaid