Provider Demographics
NPI:1801168604
Name:ELLIS, SHARON JORDAN (RN)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:JORDAN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 HWY 19 S
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31719-9273
Mailing Address - Country:US
Mailing Address - Phone:229-928-0561
Mailing Address - Fax:229-928-9935
Practice Address - Street 1:415 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3015
Practice Address - Country:US
Practice Address - Phone:229-931-2470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN079315101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor