Provider Demographics
NPI:1740075670
Name:ELLIBY, JALICA
Entity type:Individual
Prefix:
First Name:JALICA
Middle Name:
Last Name:ELLIBY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5121 SWEET BAY ST APT 205
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-5981
Mailing Address - Country:US
Mailing Address - Phone:631-375-5240
Mailing Address - Fax:
Practice Address - Street 1:5121 SWEET BAY ST APT 205
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-5981
Practice Address - Country:US
Practice Address - Phone:631-375-5240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-11
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
No172A00000XOther Service ProvidersDriver