Provider Demographics
NPI:1790506327
Name:ELLIS, JEREMY EDWARD
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:EDWARD
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5625 WILDFLOWER CT
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-8882
Mailing Address - Country:US
Mailing Address - Phone:870-558-9234
Mailing Address - Fax:
Practice Address - Street 1:1900 STILLWATER DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-9119
Practice Address - Country:US
Practice Address - Phone:870-336-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist