Provider Demographics
NPI:1780789370
Name:ELLINGSON, JVONNE L (CCDCT)
Entity type:Individual
Prefix:MRS
First Name:JVONNE
Middle Name:L
Last Name:ELLINGSON
Suffix:
Gender:F
Credentials:CCDCT
Other - Prefix:MISS
Other - First Name:JVONNE
Other - Middle Name:L
Other - Last Name:HEARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCDCT
Mailing Address - Street 1:PO BOX 1030
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201
Mailing Address - Country:US
Mailing Address - Phone:605-886-0123
Mailing Address - Fax:605-886-5447
Practice Address - Street 1:123 19TH STREET NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201
Practice Address - Country:US
Practice Address - Phone:605-886-0123
Practice Address - Fax:605-886-5447
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4293101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5001040Medicaid