Provider Demographics
NPI:1720786031
Name:ELLIS, JASON DEAN (LMFT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DEAN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1642 W MORTEN AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-7060
Mailing Address - Country:US
Mailing Address - Phone:602-999-8389
Mailing Address - Fax:
Practice Address - Street 1:1642 W MORTEN AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-7060
Practice Address - Country:US
Practice Address - Phone:602-999-8389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMFT15837106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist