Provider Demographics
NPI:1720052483
Name:ELLIS, JILL MARIE (PA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:MARIE
Other - Last Name:VISSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-455-5000
Mailing Address - Fax:
Practice Address - Street 1:4967 CROOKS RD STE 130
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-5812
Practice Address - Country:US
Practice Address - Phone:248-952-1601
Practice Address - Fax:248-952-0192
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003809363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P14500005Medicare PIN
N48650008Medicare PIN
P58193Medicare UPIN